PFD report

Eden Anna Street · Prevention of Future Deaths report

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Issued 10 Jan 2025•East Riding and Hull

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
1

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
9

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 to feed back telephone helpline information about autistic children to the weekly audit meeting and clinical priority decision-makers
    Part of recurring concern: Unreliable capture and onward use of telephone helpline information
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.3

  1. Action

    Require increased-risk contacts handled by duty workers to be discussed within three working days at the next waiting-list or multidisciplinary team meeting.

    Stated by Humber Teaching NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 13 January 2025.
  2. Action

    Introduce a duty-team risk review form capturing waiting-list calls, information received, actions, and clinical rationale for meeting-based review.

    Stated by Humber Teaching NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 13 January 2025.
  3. Action

    Include checks of risk review form use in future record-keeping audits.

    Stated by Humber Teaching NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 13 January 2025.

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

  1. Position

    The Trust disputes that the reported case involved its services or provides evidence of a systemic issue affecting CAMHS waiting-list contacts.

    Stated by Humber Teaching NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

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 feed back telephone helpline information about autistic children to the weekly audit meeting and clinical priority decision-makers

Wider context from the report

“Whereas the Humber Teaching NHS Foundation Trust has implemented a number of measures following the publication of a Serious Incident Investigation Report in light of admitted failings, evidence was heard that information provided by parents of autistic children via a telephone helpline operated by the Trust, is not fed back to the weekly audit meeting convened by the Trust. As a result, information about children with neurodiversity issues that might have altered for the worse, may not be available to those who can alter their clinical priorities. ”

Is this part of a recurring concern?

Yes — Unreliable capture and onward use of telephone helpline information.

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

Require increased-risk contacts handled by duty workers to be discussed within three working days at the next waiting-list or multidisciplinary team meeting.

Verbatim wording from the response

“An additional safeguard is that where contact about a young person has been received and dealt with as above by the duty worker, then where there is an increase in risk (e.g. expressions of suicidality of any degree, or a change in known risk profile, no matter what the outcome of that contact, the contact is referenced within a clinical discussion within three working days at the weekly waiting list or weekly MDT meeting (whichever is next due to take place). This gives an opportunity for any further input into the information and decision-making to be provided by the broader professional group. This would include cases where the outcome of the contact is that there will be no change to clinical prioritisation, and this gives an opportunity for this decision to be “double checked” by the wider group and safeguarding responses provided if required.”

Source location

Response from Humber Teaching NHS Foundation Trust
Page 2 · response
Published 13 January 2025

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 duty-team risk review form capturing waiting-list calls, information received, actions, and clinical rationale for meeting-based review.

Verbatim wording from the response

“Additionally, the Trust is implementing a new electronic record keeping system and as part of that, is introducing a risk review form for use by the duty team which will capture calls made to the service. The form will outline the nature of the call and the information provided, and the agreed actions with the supporting clinical rationale. This form will be used as the basis for review of such contacts in the weekly waiting list or weekly MDT meetings. (The use of these forms is just being introduced now with the new electronic system and in the future record keeping audits will include checks to see they are being utilised.)”

Source location

Response from Humber Teaching NHS Foundation Trust
Page 2 · response
Published 13 January 2025

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

Include checks of risk review form use in future record-keeping audits.

Verbatim wording from the response

“Additionally, the Trust is implementing a new electronic record keeping system and as part of that, is introducing a risk review form for use by the duty team which will capture calls made to the service. The form will outline the nature of the call and the information provided, and the agreed actions with the supporting clinical rationale. This form will be used as the basis for review of such contacts in the weekly waiting list or weekly MDT meetings. (The use of these forms is just being introduced now with the new electronic system and in the future record keeping audits will include checks to see they are being utilised.)”

Source location

Response from Humber Teaching NHS Foundation Trust
Page 2 · response
Published 13 January 2025

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 Trust disputes that the reported case involved its services or provides evidence of a systemic issue affecting CAMHS waiting-list contacts.

Verbatim wording from the response

“The Trust made further enquiries via those representing Eden’s family and sought detail of the case that had been referred to during the Inquest, which we understand was the basis for the PFD report. Helpful information was forthcoming including the name of the child, which enabled the Trust to review that matter. It transpires that child was not and is not on the Trust’s Core CAMHS waiting list and the circumstances pertaining to that child do not in any way relate to the substantive issue raised within the PFD report.”

Source location

Response from Humber Teaching NHS Foundation Trust
Page 1 · response
Published 13 January 2025

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.6

  1. 1

    Commission Matthew’s Hub to provide specialist autism-related waiting-list support for young people and parents through mentoring, training, groups, and school engagement.

    Stated by Humber Teaching NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 13 January 2025.
  2. 2

    Operate a dedicated senior-clinician duty system to receive waiting-list calls, assess changes in presentation or risk, safety-plan, and determine appropriate escalation.

    Stated by Humber Teaching NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 13 January 2025.
  3. 3

    Implement a new electronic record-keeping system for the service.

    Stated by Humber Teaching NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 13 January 2025.
  4. 4

    Incorporate autism-related information into duty-team assessments and decision-making for waiting-list patients diagnosed with or awaiting assessment for autism.

    Stated by Humber Teaching NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 13 January 2025.
  5. 5

    Establish daily safety huddles from March 2025 to enable duty clinicians to raise concerns and obtain wider clinical perspectives.

    Stated by Humber Teaching NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 13 January 2025.
  6. 6

    Require all Trust staff to receive Oliver McGowan Mandatory Training on Learning Disability and Autism.

    Stated by Humber Teaching NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 13 January 2025.

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

  1. 1

    The Trust considers its existing system for handling contacts concerning children on the CAMHS waiting list robust and sufficient.

    Stated by Humber Teaching NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.

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

Commission Matthew’s Hub to provide specialist autism-related waiting-list support for young people and parents through mentoring, training, groups, and school engagement.

Verbatim wording from the response

“The duty team incorporate this into their assessments and decision making for those on the waiting list that may have a diagnosis or be awaiting assessment for autism. Matthew’s Hub, a specific autism charity has been commissioned as waiting list support. They are a specialist voluntary agency who can be directly contracted through Humber Teaching NHS Foundation Trust to offer waiting list support to young people aged 13+ and parents of all-age children. This support currently involves one-to-one sessions with a peer mentor; topics are needs-led; training sessions for young people and parents; school training, a youth club and small group sessions on specific issues (as identified by young people), for example, emotional regulation, daily living skills.”

Source location

Response from Humber Teaching NHS Foundation Trust
Page 2 · response
Published 13 January 2025

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 dedicated senior-clinician duty system to receive waiting-list calls, assess changes in presentation or risk, safety-plan, and determine appropriate escalation.

Verbatim wording from the response

“If a call is received about a child on the waiting list, we have dedicated duty workers, who are senior band 7 nurses, whose sole responsibility is to operate the duty system, a large part of the role being to receive calls into the service. The senior clinician receiving the call will ascertain the nature of the information, and where the call is related to concerns or changes related to mental health presentation or safeguarding information, they will gather information and assess need via the telephone in this call. Immediate safety planning work will be included as clinically indicated. Further to the call, a decision will be made regarding next appropriate steps which may form part of the safety plan.”

Source location

Response from Humber Teaching NHS Foundation Trust
Page 2 · response
Published 13 January 2025

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 new electronic record-keeping system for the service.

Verbatim wording from the response

“Additionally, the Trust is implementing a new electronic record keeping system and as part of that, is introducing a risk review form for use by the duty team which will capture calls made to the service. The form will outline the nature of the call and the information provided, and the agreed actions with the supporting clinical rationale. This form will be used as the basis for review of such contacts in the weekly waiting list or weekly MDT meetings. (The use of these forms is just being introduced now with the new electronic system and in the future record keeping audits will include checks to see they are being utilised.)”

Source location

Response from Humber Teaching NHS Foundation Trust
Page 2 · response
Published 13 January 2025

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

Incorporate autism-related information into duty-team assessments and decision-making for waiting-list patients diagnosed with or awaiting assessment for autism.

Verbatim wording from the response

“The duty team incorporate this into their assessments and decision making for those on the waiting list that may have a diagnosis or be awaiting assessment for autism. Matthew’s Hub, a specific autism charity has been commissioned as waiting list support. They are a specialist voluntary agency who can be directly contracted through Humber Teaching NHS Foundation Trust to offer waiting list support to young people aged 13+ and parents of all-age children. This support currently involves one-to-one sessions with a peer mentor; topics are needs-led; training sessions for young people and parents; school training, a youth club and small group sessions on specific issues (as identified by young people), for example, emotional regulation, daily living skills.”

Source location

Response from Humber Teaching NHS Foundation Trust
Page 2 · response
Published 13 January 2025

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

Establish daily safety huddles from March 2025 to enable duty clinicians to raise concerns and obtain wider clinical perspectives.

Verbatim wording from the response

“Additionally, the team are establishing ‘safety huddles’ in March 2025, which are a brief daily meeting allowing for staff to raise any areas of concern – this will provide a more frequent forum for duty clinicians to gain wider clinical perspectives on decision making.”

Source location

Response from Humber Teaching NHS Foundation Trust
Page 2 · response
Published 13 January 2025

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 all Trust staff to receive Oliver McGowan Mandatory Training on Learning Disability and Autism.

Verbatim wording from the response

“These could include further telephone contact with the young person or their carer, a face-to-face contact with the young person, a referral to the crisis and/or intensive home treatment service for more prompt intervention if clinically indicated, or the young person’s referral to the waiting list as “routine” could be upgraded to “urgent” and allocated accordingly. Having senior clinicians undertaking this role provides assurance that we have a consistent and expert response to calls received outside of planned contact by core CAMHS, both in relation to children who are neuro divergent and those who are not. In addition, it is now mandatory for all Trust staff to have received the Oliver McGowan Mandatory Training on Learning Disability and Autism.”

Source location

Response from Humber Teaching NHS Foundation Trust
Page 2 · response
Published 13 January 2025

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 Trust considers its existing system for handling contacts concerning children on the CAMHS waiting list robust and sufficient.

Verbatim wording from the response

“Eden’s family had referred to, which we understand was the basis for the PFD report, we do not think there is in fact evidence that there is a systemic issue or that the system was not operating as described. As detailed above, the young person is not known to the Trust’s Core CAMHS or autism services. I am reassured there is a robust system for dealing with contacts received in relation to children and young people on the CAMHS waiting list.”

Source location

Response from Humber Teaching NHS Foundation Trust
Page 3 · response
Published 13 January 2025

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