PFD report

Melanie Ruth Pinnell · Prevention of Future Deaths report

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Issued 26 Mar 2026•Suffolk

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
2

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
11

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 by GPs to action consultant psychiatrist medication requests
  2. Lack of GP practice follow-up for patients describing suicidal ideation or suicidal thoughts
    Part of recurring concern: Failure to provide sufficient GP involvement in patient care
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.8

  1. Action

    Define and reinforce clear ownership for prescribing actions and follow-up.

    Stated by Unity HealthcareStated in progressThe respondent said that this action was in progress when they made their response on 7 April 2026.
  2. Action

    Introduce a formal escalation standard operating procedure for incomplete actions.

    Stated by Unity HealthcareStated in progressThe respondent said that this action was in progress when they made their response on 7 April 2026.
  3. Action

    Introduce formal practice and mental-health-team caseload reviews covering care plans and safety-netting actions.

    Stated by Unity HealthcareStated in progressThe respondent said that this action was in progress when they made their response on 7 April 2026.

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 by GPs to action consultant psychiatrist medication requests

Wider context from the report

“The request for Sertraline 50mg once a day given by a Consultant Psychiatrist to the Primary Care Network Mental Health Care Worker was not actioned by a GP working for Unity Healthcare ”

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 GP practice follow-up for patients describing suicidal ideation or suicidal thoughts

Wider context from the report

“No follow-up was offered to Melanie by the GP practice after February 2025 despite Melanie describing suicidal ideation and suicidal thoughts ”

Is this part of a recurring concern?

Yes — Failure to provide sufficient GP involvement in patient care.

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

Define and reinforce clear ownership for prescribing actions and follow-up.

Verbatim wording from the response

“▪ Defining Ownership and Escalation: The PCN MH Clinical Lead and GP Clinical Lead for mental health are defining and re-enforcing clear ownership for prescribing actions and follow-up, as well as introducing a formal escalation SOP for incomplete actions.”

Source location

2026-0185 - Response from Unity Healthcare
Page 2 · response
Published 7 April 2026

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

Introduce a formal escalation standard operating procedure for incomplete actions.

Verbatim wording from the response

“▪ Defining Ownership and Escalation: The PCN MH Clinical Lead and GP Clinical Lead for mental health are defining and re-enforcing clear ownership for prescribing actions and follow-up, as well as introducing a formal escalation SOP for incomplete actions.”

Source location

2026-0185 - Response from Unity Healthcare
Page 2 · response
Published 7 April 2026

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

Introduce formal practice and mental-health-team caseload reviews covering care plans and safety-netting actions.

Verbatim wording from the response

“Based on our PSII findings, we are implementing the following safety actions with specific oversight and timelines:”

Source location

2026-0185 - Response from Unity Healthcare
Page 2 · response
Published 7 April 2026

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

Remove task-based prescribing requests from use.

Verbatim wording from the response

“Addressing Concern 2: Un-actioned Prescription Requests and Task Limitations”

Source location

2026-0185 - Response from Unity Healthcare
Page 2 · response
Published 7 April 2026

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 an approved formal pathway standard operating procedure for prescribing requests.

Verbatim wording from the response

“▪ Removing Task-Based Prescribing: We are removing the use of the task system for prescribing requests entirely and developing an approved, formal pathway SOP.”

Source location

2026-0185 - Response from Unity Healthcare
Page 2 · response
Published 7 April 2026

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

Record all specialist advice in both SystmOne and Lorenzo clinical systems.

Verbatim wording from the response

“▪ System Recording: To ensure visibility, all specialist advice will be recorded in both of our clinical systems, SystmOne and Lorenzo.”

Source location

2026-0185 - Response from Unity Healthcare
Page 2 · response
Published 7 April 2026

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 a review system ensuring visibility of outstanding tasks assigned to locums, absent staff, or former staff.

Verbatim wording from the response

“Outstanding Task Review System: A review system for outstanding tasks—specifically ensuring visibility of tasks assigned to locums, absent staff, or staff who have left the organisation—was implemented by Clinical Services Management in June 2025.”

Source location

2026-0185 - Response from Unity Healthcare
Page 3 · response
Published 7 April 2026

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

Complete a system-based Patient Safety Incident Investigation into the incident and its contributing vulnerabilities.

Verbatim wording from the response

“Following this incident, we commissioned a comprehensive Patient Safety Incident Investigation (PSII) in accordance with the NHS Patient Safety Incident Response Framework (PSIRF). The investigation utilised system-based analytical tools, including the Systems Engineering Initiative for Patient Safety (SEIPS) and the Yorkshire”

Source location

2026-0185 - Response from Unity Healthcare
Page 1 · response
Published 7 April 2026

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.3

  1. 1

    Present the findings and new standard operating procedures at Unity Healthcare clinical meetings.

    Stated by Unity HealthcareStated plannedThe respondent said that this action was planned when they made their response on 7 April 2026.
  2. 2

    Share an anonymised summary of task-based prescribing-message risks with the ICB Quality Lead.

    Stated by Unity HealthcareStated plannedThe respondent said that this action was planned when they made their response on 7 April 2026.
  3. 3

    Develop and implement a standard operating procedure for managing uncontactable patients.

    Stated by Unity HealthcareStated in progressThe respondent said that this action was in progress when they made their response on 7 April 2026.

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

Present the findings and new standard operating procedures at Unity Healthcare clinical meetings.

Verbatim wording from the response

“To ensure wide-reaching impact, the findings and new SOPs will be presented internally at Unity Healthcare clinical meetings. Furthermore, an anonymised summary detailing the risks of task-based messaging for prescribing requests will be shared with the Suffolk and North East Essex Integrated Care Board (ICB) Quality Lead to promote shared learning across the wider system.”

Source location

2026-0185 - Response from Unity Healthcare
Page 3 · response
Published 7 April 2026

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

Share an anonymised summary of task-based prescribing-message risks with the ICB Quality Lead.

Verbatim wording from the response

“To ensure wide-reaching impact, the findings and new SOPs will be presented internally at Unity Healthcare clinical meetings. Furthermore, an anonymised summary detailing the risks of task-based messaging for prescribing requests will be shared with the Suffolk and North East Essex Integrated Care Board (ICB) Quality Lead to promote shared learning across the wider system.”

Source location

2026-0185 - Response from Unity Healthcare
Page 3 · response
Published 7 April 2026

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 and implement a standard operating procedure for managing uncontactable patients.

Verbatim wording from the response

“▪ Managing Uncontactable Patients: We are standardising the process for managing uncontactable patients by developing and implementing a new Standard Operating Procedure (SOP).”

Source location

2026-0185 - Response from Unity Healthcare
Page 2 · response
Published 7 April 2026

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