PFD report

Susan Janet ADAMS · Prevention of Future Deaths report

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Issued 21 Apr 2021•Staffordshire 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
2

Named on the report

Responses found
1

Of 2 recipients

Stated actions
1

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 raised1

  1. Failure of cross-county commissioning arrangements to ensure coordinated secondary psychiatric care
    Part of recurring concern: Failure to integrate mental health services across care settings
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.1

  1. Action

    Forward the county-boundary care concern to commissioners for consideration.

    Stated by Midlands Partnership University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 23 April 2021.

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

  1. Position

    Commissioners are responsible for considering the cross-boundary care arrangements and any resulting action.

    Stated by Midlands Partnership University NHS Foundation TrustRedirects 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

Failure of cross-county commissioning arrangements to ensure coordinated secondary psychiatric care

Wider context from the report

“Mrs Adams and her family lived in Dosthill, Tamworth, Staffordshire. I was told that this was approximately 50 feet from the border with Warwickshire (and not far from West Midlands as well) and that her GP Practice was in Kingsbury Warwickshire. She needed regular psychiatric assistance from secondary mental health services and I was advised there were significant commissioning difficulties with this because of the home address and GP Practice being in different counties. Mrs Adams could access the crisis team in Staffordshire but long term treatment was supposedly to be provided in Warwickshire. This may have impacted on the care that Mrs Adams received and could be relevant for others who live close to county boundaries. I wonder if anything can be done to facilitate arrangements for secondary psychiatric care in these circumstances. ”

Is this part of a recurring concern?

Yes — Failure to integrate mental health services across care settings.

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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

Forward the county-boundary care concern to commissioners for consideration.

Verbatim wording from the response

“However, given your concerns, we believe the matter is one for commissioners to consider and have therefore forwarded this case to them for their consideration and are happy to support the outcome of those conversations, as appropriate.”

Source location

2021-0116-Response-from-St-Georges-Hospital_Published
Page 2 · response
Published 23 April 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

Commissioners are responsible for considering the cross-boundary care arrangements and any resulting action.

Verbatim wording from the response

“However, given your concerns, we believe the matter is one for commissioners to consider and have therefore forwarded this case to them for their consideration and are happy to support the outcome of those conversations, as appropriate.”

Source location

2021-0116-Response-from-St-Georges-Hospital_Published
Page 2 · response
Published 23 April 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 collaborative arrangements between providers ensure people living near county boundaries are not disadvantaged in accessing services.

Verbatim wording from the response

“Throughout all of Mrs Adams’ episodes of care, including that in 2020, MPFT has worked well with partners to ensure people living on the county border are not disadvantaged in terms of services offered and in delivering patient-centred collaborative working between organisations.”

Source location

2021-0116-Response-from-St-Georges-Hospital_Published
Page 2 · response
Published 23 April 2021

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

  1. 1

    The 2020 difficulties were attributed to alcohol misuse, with no acute mental health problems requiring secondary mental health services.

    Stated by Midlands Partnership University NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

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 2020 difficulties were attributed to alcohol misuse, with no acute mental health problems requiring secondary mental health services.

Verbatim wording from the response

“Throughout this period Mrs Adams’ difficulties were deemed to be related to alcohol misuse with no acute mental health problems that would require secondary mental health services. In earlier years when Mrs Adams did require a secondary mental health services (1999 – 2005, 2014-2015, 2018, 2019) this was offered by MPFT (or the predecessor organisation South Staffordshire and Shropshire Foundation Trust).”

Source location

2021-0116-Response-from-St-Georges-Hospital_Published
Page 2 · response
Published 23 April 2021

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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