PFD report

Benjamin Colin Williamson · Prevention of Future Deaths report

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Issued 12 Dec 2018•Cornwall and Isles of Scilly

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
4

Raised in this report

Recipients
3

Named on the report

Responses found
2

Of 3 recipients

Stated actions
14

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 raised4

  1. Failure of Addaction to communicate and provide feedback to GPs
  2. Failure to consider consent for disclosure to GPs at Recovery Plan reviews
  3. Lack of consideration of underlying mental health issues in patients with alcohol or drug problems
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.10

  1. Action

    Introduce Halo monitoring, reporting and line-management oversight to ensure three-monthly confidentiality and consent reviews are completed and recorded.

    Stated by Addaction CornwallStated completedThe respondent said that this action was complete when they made their response on 13 May 2019.
  2. Action

    Have the designated practice worker attend multidisciplinary team meetings, access SystemOne and update records to improve information sharing.

    Stated by Addaction CornwallStated plannedThe respondent said that this action was planned when they made their response on 13 May 2019.
  3. Action

    Review and improve procedures for recording confidentiality and consent reviews and sharing information with primary care.

    Stated by Addaction CornwallStated completedThe respondent said that this action was complete when they made their response on 13 May 2019.

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

  1. Position

    The review recommended no policy changes to consent and information-sharing procedures, although operational improvements were agreed.

    Stated by Addaction CornwallNo action considered necessaryThe respondent said that 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

Failure of Addaction to communicate and provide feedback to GPs

Wider context from the report

“CMHT Commissioners At inquest, I heard from ████████, a partner at Mullion and Constantine Group Practice and the Locality Lead for Commissioning. Mr Williamson was his patient. ███ told me that Mr Williamson had been referred twice to CMHT. On both occasions, ████████ described this as having a significant impact upon his patient who was left feeling he was not ill enough to be worthy of support. ████████ expressed his view that the system is not set up to serve the population. He said it was his experience that patients like Benjamin are bounced between the various mental health services seemingly with ████████ one willing or able to accept responsibility for providing professional care, and he felt it had failed to meet the needs of his patient. ████████ identified that the problem was particularly acute for patients who have a mental health issue plus an alcohol (or drug) problem. He felt that while referring Benjamin to Addaction had addressed his alcohol-related concerns, there had been a total lack of consideration of any underlying mental health issue. This is not the first occasion on which observations of this nature have been made before me although in ████████ I have rarely had a more articulate or well-placed witness. Addaction ████████ told me that after referring Benjamin to Addaction he had no communications or feedback from the service. I heard from ████████ in this regard. It was accepted that there should have been more liaison with the GP and that, in particular, a letter from the doctor in January 2018 was not answered and should have been. Upon further exploration, it emerged that Benjamin had not given full consent for disclosure to his GP. I was told that his Recovery Plan had been reviewed on 25/5/17, 16/8/17, 27/10/17 and 12/2/18. I was advised that the issue of consent should have been considered at these reviews but that did not appear to have happened. Both Benjamin’s mother and ████████ were of the view that if this matter had been dealt with fully, consent for disclosure to the GP would have been provided. ████████ felt that the lack of feedback compromised his ability to provide care to his patient. ”

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

Failure to consider consent for disclosure to GPs at Recovery Plan reviews

Wider context from the report

“CMHT Commissioners At inquest, I heard from ████████, a partner at Mullion and Constantine Group Practice and the Locality Lead for Commissioning. Mr Williamson was his patient. ███ told me that Mr Williamson had been referred twice to CMHT. On both occasions, ████████ described this as having a significant impact upon his patient who was left feeling he was not ill enough to be worthy of support. ████████ expressed his view that the system is not set up to serve the population. He said it was his experience that patients like Benjamin are bounced between the various mental health services seemingly with ████████ one willing or able to accept responsibility for providing professional care, and he felt it had failed to meet the needs of his patient. ████████ identified that the problem was particularly acute for patients who have a mental health issue plus an alcohol (or drug) problem. He felt that while referring Benjamin to Addaction had addressed his alcohol-related concerns, there had been a total lack of consideration of any underlying mental health issue. This is not the first occasion on which observations of this nature have been made before me although in ████████ I have rarely had a more articulate or well-placed witness. Addaction ████████ told me that after referring Benjamin to Addaction he had no communications or feedback from the service. I heard from ████████ in this regard. It was accepted that there should have been more liaison with the GP and that, in particular, a letter from the doctor in January 2018 was not answered and should have been. Upon further exploration, it emerged that Benjamin had not given full consent for disclosure to his GP. I was told that his Recovery Plan had been reviewed on 25/5/17, 16/8/17, 27/10/17 and 12/2/18. I was advised that the issue of consent should have been considered at these reviews but that did not appear to have happened. Both Benjamin’s mother and ████████ were of the view that if this matter had been dealt with fully, consent for disclosure to the GP would have been provided. ████████ felt that the lack of feedback compromised his ability to provide care to his patient. ”

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 consideration of underlying mental health issues in patients with alcohol or drug problems

Wider context from the report

“CMHT Commissioners At inquest, I heard from ████████, a partner at Mullion and Constantine Group Practice and the Locality Lead for Commissioning. Mr Williamson was his patient. ███ told me that Mr Williamson had been referred twice to CMHT. On both occasions, ████████ described this as having a significant impact upon his patient who was left feeling he was not ill enough to be worthy of support. ████████ expressed his view that the system is not set up to serve the population. He said it was his experience that patients like Benjamin are bounced between the various mental health services seemingly with ████████ one willing or able to accept responsibility for providing professional care, and he felt it had failed to meet the needs of his patient. ████████ identified that the problem was particularly acute for patients who have a mental health issue plus an alcohol (or drug) problem. He felt that while referring Benjamin to Addaction had addressed his alcohol-related concerns, there had been a total lack of consideration of any underlying mental health issue. This is not the first occasion on which observations of this nature have been made before me although in ████████ I have rarely had a more articulate or well-placed witness. Addaction ████████ told me that after referring Benjamin to Addaction he had no communications or feedback from the service. I heard from ████████ in this regard. It was accepted that there should have been more liaison with the GP and that, in particular, a letter from the doctor in January 2018 was not answered and should have been. Upon further exploration, it emerged that Benjamin had not given full consent for disclosure to his GP. I was told that his Recovery Plan had been reviewed on 25/5/17, 16/8/17, 27/10/17 and 12/2/18. I was advised that the issue of consent should have been considered at these reviews but that did not appear to have happened. Both Benjamin’s mother and ████████ were of the view that if this matter had been dealt with fully, consent for disclosure to the GP would have been provided. ████████ felt that the lack of feedback compromised his ability to provide care to his patient. ”

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

Failure of mental health services to accept responsibility for providing professional care

Wider context from the report

“CMHT Commissioners At inquest, I heard from ████████, a partner at Mullion and Constantine Group Practice and the Locality Lead for Commissioning. Mr Williamson was his patient. ███ told me that Mr Williamson had been referred twice to CMHT. On both occasions, ████████ described this as having a significant impact upon his patient who was left feeling he was not ill enough to be worthy of support. ████████ expressed his view that the system is not set up to serve the population. He said it was his experience that patients like Benjamin are bounced between the various mental health services seemingly with ████████ one willing or able to accept responsibility for providing professional care, and he felt it had failed to meet the needs of his patient. ████████ identified that the problem was particularly acute for patients who have a mental health issue plus an alcohol (or drug) problem. He felt that while referring Benjamin to Addaction had addressed his alcohol-related concerns, there had been a total lack of consideration of any underlying mental health issue. This is not the first occasion on which observations of this nature have been made before me although in ████████ I have rarely had a more articulate or well-placed witness. Addaction ████████ told me that after referring Benjamin to Addaction he had no communications or feedback from the service. I heard from ████████ in this regard. It was accepted that there should have been more liaison with the GP and that, in particular, a letter from the doctor in January 2018 was not answered and should have been. Upon further exploration, it emerged that Benjamin had not given full consent for disclosure to his GP. I was told that his Recovery Plan had been reviewed on 25/5/17, 16/8/17, 27/10/17 and 12/2/18. I was advised that the issue of consent should have been considered at these reviews but that did not appear to have happened. Both Benjamin’s mother and ████████ were of the view that if this matter had been dealt with fully, consent for disclosure to the GP would have been provided. ████████ felt that the lack of feedback compromised his ability to provide care to his patient. ”

Is this part of a recurring concern?

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

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

Introduce Halo monitoring, reporting and line-management oversight to ensure three-monthly confidentiality and consent reviews are completed and recorded.

Verbatim wording from the response

“Improvements to recording confidentiality and consent reviews within Addaction Since December 2018 we have introduced a monitoring function into our patient management system (Halo). This will ensure that the three monthly reviews are conducted and recorded in line with our policy requirements. We now have ability to run reports,”

Source location

2018-0384-Response-by-Addaction
Page 1 · response
Published 13 May 2019

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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

Have the designated practice worker attend multidisciplinary team meetings, access SystemOne and update records to improve information sharing.

Verbatim wording from the response

“2. In order to improve communication our designated practice worker will attend the practice multi-disciplinary team meetings. They will also be able to access the patient”

Source location

2018-0384-Response-by-Addaction
Page 2 · response
Published 13 May 2019

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

Review and improve procedures for recording confidentiality and consent reviews and sharing information with primary care.

Verbatim wording from the response

“Following the request into the death of Mr Benjamin Colin Williamson on November 8th you wrote to ████████, Operations Manager asking that Addaction review the processes/procedures in place for dealing with consent and the sharing of information with Primary Care providers. In addition you asked that we involve ████████ so that lessons learned would be identified and shared.”

Source location

2018-0384-Response-by-Addaction
Page 1 · response
Published 13 May 2019

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

Reinforce with staff that informal communication must not replace formal communication channels between people involved in client care.

Verbatim wording from the response

“Our colleagues in Primary Care recognise that some patients will be reluctant to allow information to be shared with their GPs or attend specialist provision within the practice, preferring to access help and support in other locations. In Benjamin’s case decisions around information sharing with his GP and where he accessed sessions may have been influenced as his mother ████████ worked at the Mullion Health Centre. Addaction is clear that the informal communication between a parent and their employer should not replace formal communication channels between those involved in a clients care and we have reinforced this with all our staff members.”

Source location

2018-0384-Response-by-Addaction
Page 2 · response
Published 13 May 2019

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

Inform GPs earlier about plans to end structured treatment or move to Recovery Support when consent to share information exists.

Verbatim wording from the response

“3. Where consent to share information with a GP exists, Addaction will inform them at an earlier stage regarding plans to cease structured treatment / move to support that the client initiates (known as Recovery Support)”

Source location

2018-0384-Response-by-Addaction
Page 3 · response
Published 13 May 2019

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 a robust multi-agency implementation plan for the Dual Diagnosis Strategy.

Verbatim wording from the response

“An exceptional Crisis Care Concordat meeting was held on the 22 January 2019. The meeting was well-attended by the relevant statutory organisations and providers. The purpose of this meeting was for providers to agree a way forward and specific actions have been identified to review the Dual Diagnosis Strategy and implement a robust multi-agency implementation plan. A draft implementation strategy completed by NHS Kernow provided the focus of the meeting. The providers of services will chair a monthly Implementation Steering Group in order to develop the draft implementation plan. The chair will rotate quarterly between the various providers ensuring a sharing of responsibilities and commitment to improving integrated working.”

Source location

2018-0384-Response-by-Kernow-CCG-NHS-Trust
Page 2 · response
Published 13 May 2019

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

Review contract requirements for providers supporting people with dual diagnosis under the new contract commencing April 2019.

Verbatim wording from the response

“NHS Kernow is reviewing the contract requirements for new contract commencing April 2019, in relation to providers supporting individuals with a dual diagnosis. Whilst current contracts and the multi-agency strategy already specify how providers should meet the needs of people”

Source location

2018-0384-Response-by-Kernow-CCG-NHS-Trust
Page 2 · response
Published 13 May 2019

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

Operate a monthly Multiagency Implementation Steering Group with rotating provider leadership to develop the implementation plan.

Verbatim wording from the response

“An exceptional Crisis Care Concordat meeting was held on the 22 January 2019. The meeting was well-attended by the relevant statutory organisations and providers. The purpose of this meeting was for providers to agree a way forward and specific actions have been identified to review the Dual Diagnosis Strategy and implement a robust multi-agency implementation plan. A draft implementation strategy completed by NHS Kernow provided the focus of the meeting. The providers of services will chair a monthly Implementation Steering Group in order to develop the draft implementation plan. The chair will rotate quarterly between the various providers ensuring a sharing of responsibilities and commitment to improving integrated working.”

Source location

2018-0384-Response-by-Kernow-CCG-NHS-Trust
Page 2 · response
Published 13 May 2019

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 a dynamic risk register to identify and collaboratively review people at risk with dual diagnosis.

Verbatim wording from the response

“It is expected that the review of the strategy and comprehensive development of the implementation plan will be completed in six months. Whilst this is being undertaken priority will be given to actions that can be undertaken immediately and will support individuals with a dual diagnosis. For example, the development of a dynamic risk register so that people at risk can be identified and reviewed collaboratively. A similar register has been implemented for another group of people who have specific needs and has provided positive outcomes.”

Source location

2018-0384-Response-by-Kernow-CCG-NHS-Trust
Page 2 · response
Published 13 May 2019

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

Review the Cornwall and Isles of Scilly Dual Diagnosis Strategy for Adults.

Verbatim wording from the response

“An exceptional Crisis Care Concordat meeting was held on the 22 January 2019. The meeting was well-attended by the relevant statutory organisations and providers. The purpose of this meeting was for providers to agree a way forward and specific actions have been identified to review the Dual Diagnosis Strategy and implement a robust multi-agency implementation plan. A draft implementation strategy completed by NHS Kernow provided the focus of the meeting. The providers of services will chair a monthly Implementation Steering Group in order to develop the draft implementation plan. The chair will rotate quarterly between the various providers ensuring a sharing of responsibilities and commitment to improving integrated working.”

Source location

2018-0384-Response-by-Kernow-CCG-NHS-Trust
Page 2 · response
Published 13 May 2019

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

The review recommended no policy changes to consent and information-sharing procedures, although operational improvements were agreed.

Verbatim wording from the response

“Whilst no policy changes were recommended through the review process, moving forward the following actions have been agreed”

Source location

2018-0384-Response-by-Addaction
Page 2 · response
Published 13 May 2019

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.4

  1. 1

    Provide the Health Centre with numbers of registered practice clients accessing Addaction services.

    Stated by Addaction CornwallStated plannedThe respondent said that this action was planned when they made their response on 13 May 2019.
  2. 2

    Meet with Mullion Health Centre colleagues to identify lessons learned and agree required improvements.

    Stated by Addaction CornwallStated completedThe respondent said that this action was complete when they made their response on 13 May 2019.
  3. 3

    Share consent and confidentiality policies with primary care colleagues and improve their awareness of Addaction’s information-sharing approach.

    Stated by Addaction CornwallStated completedThe respondent said that this action was complete when they made their response on 13 May 2019.
  4. 4

    Report the Multiagency Implementation Steering Group’s progress to the Crisis Care Concordat in April 2019.

    Stated by NHS Cornwall and the Isles of Scilly Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 13 May 2019.

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 the Health Centre with numbers of registered practice clients accessing Addaction services.

Verbatim wording from the response

“Whilst no policy changes were recommended through the review process, moving forward the following actions have been agreed”

Source location

2018-0384-Response-by-Addaction
Page 2 · response
Published 13 May 2019

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

Meet with Mullion Health Centre colleagues to identify lessons learned and agree required improvements.

Verbatim wording from the response

“I am writing to confirm that we have internally reviewed and improved how we record confidentiality and consent reviews, shared copies of Addaction’s consent and confidentiality policy (DQ225) and met with ████████ and colleagues at the Mullion Health Centre on 30th January 2019 to identify lessons learned and agree any required improvements.”

Source location

2018-0384-Response-by-Addaction
Page 1 · response
Published 13 May 2019

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 consent and confidentiality policies with primary care colleagues and improve their awareness of Addaction’s information-sharing approach.

Verbatim wording from the response

“I am writing to confirm that we have internally reviewed and improved how we record confidentiality and consent reviews, shared copies of Addaction’s consent and confidentiality policy (DQ225) and met with ████████ and colleagues at the Mullion Health Centre on 30th January 2019 to identify lessons learned and agree any required improvements.”

Source location

2018-0384-Response-by-Addaction
Page 1 · response
Published 13 May 2019

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

Report the Multiagency Implementation Steering Group’s progress to the Crisis Care Concordat in April 2019.

Verbatim wording from the response

“The progress of the Multiagency Implementation Steering Group will be reported to the Crisis Care Concordat in April 2019 with a future proposal to establish this reporting line to Safer Cornwall.”

Source location

2018-0384-Response-by-Kernow-CCG-NHS-Trust
Page 2 · response
Published 13 May 2019

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