PFD report

Paul Robert Allan · Prevention of Future Deaths report

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Issued 25 Jul 2018•Inner West London

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
2

Named on the report

Responses found
1

Of 2 recipients

Stated actions
5

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 consult or work with drug and alcohol advisory services
    Part of recurring concern: Failure to integrate mental health services across care settings
  2. Failure to transfer people between community mental health teams when they move
    Part of recurring concern: Failure to integrate mental health services across care settingsPart of recurring concern: Unsafe coordination and continuity during mental health service transfers
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.2

  1. Action

    Continue development meetings between drug and alcohol and Rochdale mental health operational managers to support and enhance the dual-diagnosis model.

    Stated by Pennine Care NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 24 September 2018.
  2. Action

    Develop new posts to bridge dual-diagnosis service gaps and establish pathways and effective working practices between mental health and drug and alcohol services.

    Stated by Pennine Care NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 24 September 2018.

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 consult or work with drug and alcohol advisory services

Wider context from the report

“2) The Rochdale community Mental Health Team failed to consult or work with the Drug and Alcohol advisory services in relation to Paul Robert Allan as it is required to do. ”

Is this part of a recurring concern?

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

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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 people between community mental health teams when they move

Wider context from the report

“1) The Rochdale Community Mental Health Team discharged Paul Robert Allan from their care instead of transferring him to the Community Mental Health Team in Stoke where Paul Robert Allan was moving to. ”

Is this part of a recurring concern?

Yes — Failure to integrate mental health services across care settings; Unsafe coordination and continuity during mental health service transfers.

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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

Continue development meetings between drug and alcohol and Rochdale mental health operational managers to support and enhance the dual-diagnosis model.

Verbatim wording from the response

“The Trust has recognised the gap in services for dual diagnoses clients and the difficulties experienced in Rochdale as a result of the commissioning arrangements around Drug and Alcohol services being delivered by third sector organisations. As such the Trust has recently been successful in their application for Greater Manchester funding from the transformation fund, to develop new posts to bridge this gap. The new posts will develop and establish pathways between Mental Health and Drug and alcohol services and work with the most complex clients and develop effective working practices. Further development meetings with the operational manager of the drug and alcohol services and Rochdale mental health services are supporting and enhancing this model.”

Source location

2018-0251-Response-by-Pennine-Care-NHS-Trust
Page 2 · response
Published 24 September 2018

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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

Develop new posts to bridge dual-diagnosis service gaps and establish pathways and effective working practices between mental health and drug and alcohol services.

Verbatim wording from the response

“The Trust has recognised the gap in services for dual diagnoses clients and the difficulties experienced in Rochdale as a result of the commissioning arrangements around Drug and Alcohol services being delivered by third sector organisations. As such the Trust has recently been successful in their application for Greater Manchester funding from the transformation fund, to develop new posts to bridge this gap. The new posts will develop and establish pathways between Mental Health and Drug and alcohol services and work with the most complex clients and develop effective working practices. Further development meetings with the operational manager of the drug and alcohol services and Rochdale mental health services are supporting and enhancing this model.”

Source location

2018-0251-Response-by-Pennine-Care-NHS-Trust
Page 2 · response
Published 24 September 2018

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

    Include CPA in the 2018/19 clinical audit programme.

    Stated by Pennine Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 24 September 2018.
  2. 2

    Circulate a reminder to staff explaining how to access and use the CPA policy in practice.

    Stated by Pennine Care NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 24 September 2018.
  3. 3

    Work collaboratively with partner agencies to apply NCISH suicide-prevention recommendations in practice.

    Stated by Pennine Care NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 24 September 2018.

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 CPA in the 2018/19 clinical audit programme.

Verbatim wording from the response

“As a Trust we will circulate a reminder to all staff regarding the policy to include how to access the policy and its use in practice. It is a duty of all responsible clinicians and registered practitioners to take accountability for clinical decision making adhering to nation and local policy and guidance. The Trust have also ensured that CPA is included on clinical audit programme 2018/19”

Source location

2018-0251-Response-by-Pennine-Care-NHS-Trust
Page 2 · response
Published 24 September 2018

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

Circulate a reminder to staff explaining how to access and use the CPA policy in practice.

Verbatim wording from the response

“As a Trust we will circulate a reminder to all staff regarding the policy to include how to access the policy and its use in practice. It is a duty of all responsible clinicians and registered practitioners to take accountability for clinical decision making adhering to nation and local policy and guidance. The Trust have also ensured that CPA is included on clinical audit programme 2018/19”

Source location

2018-0251-Response-by-Pennine-Care-NHS-Trust
Page 2 · response
Published 24 September 2018

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

Work collaboratively with partner agencies to apply NCISH suicide-prevention recommendations in practice.

Verbatim wording from the response

“Pennine Care NHS is a signatory to the Greater Manchester Strategic suicide prevention strategy and will be working collaboratively and closely with partner agencies to bring the NCISH recommendations to practice.”

Source location

2018-0251-Response-by-Pennine-Care-NHS-Trust
Page 3 · response
Published 24 September 2018

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