Felix Stefan CEMBROWICZ · Prevention of Future Deaths report

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Issued 12 Sep 2013•Avon

Published report and response evidence

This report’s concerns and statements found in recipients’ published responses. Statements are included even where no link to an individual concern is recorded. A link shows an 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
5

Described in responses

Recipients and published responses

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 to transfer important historical mental health records, including relapse management plans, into the electronic Rio record system
    Part of recurring concern: Electronic patient records failing to make relevant clinical information available and actionable

Stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.5

  1. Avon and Wiltshire Mental Health Partnership NHS Trust

    Communicate the new record-checking requirements through staff supervision processes.

  2. Avon and Wiltshire Mental Health Partnership NHS Trust

    Update RiO and information-governance training packages to reflect the new requirements.

  3. Avon and Wiltshire Mental Health Partnership NHS Trust

    Require staff to check for historic relapse or other management plans in RiO when patients are re-referred.

  4. Avon and Wiltshire Mental Health Partnership NHS Trust

    Require staff to search historic electronic and paper records for specified recent clinical documents and copy identified documents into RiO.

  5. Avon and Wiltshire Mental Health Partnership NHS Trust

    Audit implementation of the record-checking and document-transfer requirements through the records audit plan.

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 transfer important historical mental health records, including relapse management plans, into the electronic Rio record system

Wider context from the report

“The electronic Rio record system used by staff to access patient histories was introduced in May 2011 when only the documentation for current patients at that date was migrated across to the new system. Discharged patients, with both a long and recent history of contact with mental health services do not appear to have had important records transferred including relapse management plans leaving staff unaware of a patients history or delaying assessments until old records can be obtained. ”

Is this part of a recurring concern?

Yes — Electronic patient records failing to make relevant clinical information available and actionable.

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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

Communicate the new record-checking requirements through staff supervision processes.

Verbatim wording from the response

“We are using our supervision processes with staff to communicate these new requirements as well as updating our RiO and information governance training packages. We also see the inclusion of this information in the RiO record as a clinical and quality indicator and plan to audit the implementation of this change through our records audit plan.”

Source location

2013-0204-Response-by-Avon-Wiltshire-NHS
Page 2 · response
Published 12 September 2013

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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

Update RiO and information-governance training packages to reflect the new requirements.

Verbatim wording from the response

“We are using our supervision processes with staff to communicate these new requirements as well as updating our RiO and information governance training packages. We also see the inclusion of this information in the RiO record as a clinical and quality indicator and plan to audit the implementation of this change through our records audit plan.”

Source location

2013-0204-Response-by-Avon-Wiltshire-NHS
Page 2 · response
Published 12 September 2013

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

Require staff to check for historic relapse or other management plans in RiO when patients are re-referred.

Verbatim wording from the response

“In response to your concerns, we have taken the following steps:”

Source location

2013-0204-Response-by-Avon-Wiltshire-NHS
Page 2 · response
Published 12 September 2013

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

Require staff to search historic electronic and paper records for specified recent clinical documents and copy identified documents into RiO.

Verbatim wording from the response

“In response to your concerns, we have taken the following steps:”

Source location

2013-0204-Response-by-Avon-Wiltshire-NHS
Page 2 · response
Published 12 September 2013

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

Audit implementation of the record-checking and document-transfer requirements through the records audit plan.

Verbatim wording from the response

“We are using our supervision processes with staff to communicate these new requirements as well as updating our RiO and information governance training packages. We also see the inclusion of this information in the RiO record as a clinical and quality indicator and plan to audit the implementation of this change through our records audit plan.”

Source location

2013-0204-Response-by-Avon-Wiltshire-NHS
Page 2 · response
Published 12 September 2013

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