PFD report

Simion Costin · Prevention of Future Deaths report

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Issued 26 Feb 2015•Leicester City and South Leicestershire

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
1

Named on the report

Responses found
1

Of 1 recipient

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 raised2

  1. Failure to use a consistent approach during patient assessment
  2. Lack of nationally agreed standard assessment forms for cross-organisational mental health transfers
    Part 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.

No linked response statements

No respondent-stated action or position is clearly linked to these concerns.

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 use a consistent approach during patient assessment

Wider context from the report

“(1) Evidence was heard that during patient assessment, the same approach was not adopted by all clinicians. As a result standardised assessments forms have now been developed and are being used within the Leicestershire Partnership Trust. This includes the need to involve family / friends in the assessment (with the consent of the patient). However, it was recognised that mental health care often crosses borders with an initial assessment made in a neighbouring hospital but then the patient transferred for care and treatment elsewhere. The Consultant gave evidence that it would be better if there were nationally agreed standard forms so that communication in these complex situations is best served. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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 nationally agreed standard assessment forms for cross-organisational mental health transfers

Wider context from the report

“(1) Evidence was heard that during patient assessment, the same approach was not adopted by all clinicians. As a result standardised assessments forms have now been developed and are being used within the Leicestershire Partnership Trust. This includes the need to involve family / friends in the assessment (with the consent of the patient). However, it was recognised that mental health care often crosses borders with an initial assessment made in a neighbouring hospital but then the patient transferred for care and treatment elsewhere. The Consultant gave evidence that it would be better if there were nationally agreed standard forms so that communication in these complex situations is best served. ”

Is this part of a recurring concern?

Yes — Unreliable multi-agency communication procedures.

Open source report

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

    Work with agencies to improve crisis care, identify causes of crises, and develop prevention and early-intervention plans.

    Stated by Recipient name withheldStated in progressThe respondent said that this action was in progress when they made their response on 26 February 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

Work with agencies to improve crisis care, identify causes of crises, and develop prevention and early-intervention plans.

Verbatim wording from the response

“As one of the signatories to the Crisis Care Concordat, NHS England is committed to working with other agencies who come into contact with people experiencing a mental health crisis, to improve the system of care and support for people in crisis, to work together to identify the causes of crises, and put in place prevention and early intervention plans whenever possible.”

Source location

2015-0071-Response-by-NHS-England
Page 2 · response
Published 26 February 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