PFD report

Sheridan Tate Pickett · Prevention of Future Deaths report

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Issued 19 Mar 2025•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
1

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
3

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

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Concerns raised1

  1. Lack of guidelines for communication and information sharing between private psychiatry providers and NHS services providing parallel neurodiversity care
    Part of recurring concern: Unreliable coordination and escalation between care providers and mental health servicesPart of recurring concern: Unreliable inter-agency information sharing for coordinated carePart of recurring concern: Unreliable multi-agency communication procedures
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

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

  1. Position

    Existing hospital discharge guidance already governs information sharing between private and NHS providers, including medication and care information.

    Stated by Department of Health and Social CareExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.

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 guidelines for communication and information sharing between private psychiatry providers and NHS services providing parallel neurodiversity care

Wider context from the report

“1. The inquest heard evidence that Mr Pickett had a history of mental health issues and received an online diagnosis of ADHD from a private service provider (which prescribed Mr Pickett with medication too). Following his diagnosis Mr Pickett was admitted into an NHS hospital having taken an overdose. In their discharge letter the hospital suggested that the ADHD medication should not be recommenced. This information was not provided to the private ADHD provider which continued to prescribe Mr Pickett with ADHD medication. I am concerned that there are no current guidelines governing communication and information sharing as between private psychiatry providers offering assessment, care and treatment in relation to neurodiversity and NHS services involved with providing care and treatment in parallel. ”

Is this part of a recurring concern?

Yes — Unreliable coordination and escalation between care providers and mental health services; Unreliable inter-agency information sharing for coordinated care; Unreliable multi-agency communication procedures.

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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 hospital discharge guidance already governs information sharing between private and NHS providers, including medication and care information.

Verbatim wording from the response

“In your report, you raise concerns that there are no current guidelines governing communication and information sharing between private providers and NHS providers. The following guidance, Hospital discharge and community support guidance - GOV.UK states that:”

Source location

Response from DHSC
Page 2 · response
Published 26 March 2025

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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.3

  1. 1

    Continue delivering the cross-sector Suicide Prevention Strategy for England, including tailored national action for people in contact with mental health services.

    Stated by Department of Health and Social CareStated in progressThe respondent said that this action was in progress when they made their response on 26 March 2025.
  2. 2

    Recruit 8,500 new mental health workers to support people at risk of suicide.

    Stated by Department of Health and Social CareStated plannedThe respondent said that this action was planned when they made their response on 26 March 2025.
  3. 3

    Train the 8,500 new mental health workers to support people at risk of suicide.

    Stated by Department of Health and Social CareStated plannedThe respondent said that this action was planned when they made their response on 26 March 2025.

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

  1. 1

    The GMC and GPhC should be approached directly about the online provider’s procedures because they may regulate the provider.

    Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.

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 delivering the cross-sector Suicide Prevention Strategy for England, including tailored national action for people in contact with mental health services.

Verbatim wording from the response

“We are also committed to continuing to deliver the cross-sector Suicide Prevention Strategy for England published in 2023. This identifies a number of groups for tailored or targeted action at a national level, including people in contact with mental health services.”

Source location

Response from DHSC
Page 3 · response
Published 26 March 2025

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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

Recruit 8,500 new mental health workers to support people at risk of suicide.

Verbatim wording from the response

“Lastly, I would like to assure you that we are committed to tackling suicide as one the biggest killers in this country. As part of this, the 8,500 new mental health workers we will recruit will be trained to support people at risk, to reduce the lives lost to suicide.”

Source location

Response from DHSC
Page 3 · response
Published 26 March 2025

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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

Train the 8,500 new mental health workers to support people at risk of suicide.

Verbatim wording from the response

“Lastly, I would like to assure you that we are committed to tackling suicide as one the biggest killers in this country. As part of this, the 8,500 new mental health workers we will recruit will be trained to support people at risk, to reduce the lives lost to suicide.”

Source location

Response from DHSC
Page 3 · response
Published 26 March 2025

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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

The GMC and GPhC should be approached directly about the online provider’s procedures because they may regulate the provider.

Verbatim wording from the response

“To ascertain further details about procedures followed by the provider that prescribed Mr Pickett’s medication, you could directly approach the General Medical Council (GMC) and the General Pharmaceutical Council (GPhC) who may have responsibility for their regulation.”

Source location

Response from DHSC
Page 2 · response
Published 26 March 2025

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