PFD report

Claire Louise Driver · Prevention of Future Deaths report

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Issued 24 Mar 2025•South Yorkshire (Western)

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
3

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
6

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 raised3

  1. Failure to use a sufficiently assertive approach to engage people with deteriorating mental health, including in complex cases
    Part of recurring concern: Failure to recognise and respond to deteriorating mental health in service users
  2. Inadequate liaison between police and enhanced community mental health teams when people are in custody
    Part of recurring concern: Unreliable operational liaison between police and mental health services for safety-critical risk management
  3. Lack of mandatory training for all staff on the effect of substance misuse on mental health conditions
    Part of recurring concern: Unreliable dual-diagnosis care pathways
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.5

  1. Action

    Pilot a caseload-management tool requiring enhanced-team cases to be discussed with clinical leads or team managers and recording contacts, attempted contacts and meetings.

    Stated by South West Yorkshire Partnership Teaching NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 27 March 2025.
  2. Action

    Provide co-occurring mental-health and substance-misuse training as an essential-to-role course for relevant staff, identifying completion through supervision or appraisal and recording it in training records.

    Stated by South West Yorkshire Partnership Teaching NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 27 March 2025.
  3. Action

    Identify service users requiring intensive or assertive support and ensure they receive the appropriate level of care.

    Stated by South West Yorkshire Partnership Teaching NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 27 March 2025.

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

  1. Position

    Targeted training arrangements ensure staff who require substance-misuse training receive it, so mandatory training for all staff is not necessary.

    Stated by South West Yorkshire Partnership Teaching NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so 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 to use a sufficiently assertive approach to engage people with deteriorating mental health, including in complex cases

Wider context from the report

“(1) The inquest heard there were only two attempts to see Claire by the enhanced community mental health team between 28 November 2023, when she was seen in police custody, and 16 January 2024, when she was detained under the Mental Health Act, despite clear evidence her mental health was deteriorating. It was accepted in evidence a more assertive approach to attempt to engage Claire, and in complex cases generally, could have been used and there could have been better liaison between the police and the enhanced community mental health team when Claire was in custody. A more assertive approach and better liaison could have prevented Claire relapsing to such an extent she needed to be detained under the Mental Health Act. ”

Is this part of a recurring concern?

Yes — Failure to recognise and respond to deteriorating mental health in service users.

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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

Inadequate liaison between police and enhanced community mental health teams when people are in custody

Wider context from the report

“(1) The inquest heard there were only two attempts to see Claire by the enhanced community mental health team between 28 November 2023, when she was seen in police custody, and 16 January 2024, when she was detained under the Mental Health Act, despite clear evidence her mental health was deteriorating. It was accepted in evidence a more assertive approach to attempt to engage Claire, and in complex cases generally, could have been used and there could have been better liaison between the police and the enhanced community mental health team when Claire was in custody. A more assertive approach and better liaison could have prevented Claire relapsing to such an extent she needed to be detained under the Mental Health Act. ”

Is this part of a recurring concern?

Yes — Unreliable operational liaison between police and mental health services for safety-critical risk management.

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 mandatory training for all staff on the effect of substance misuse on mental health conditions

Wider context from the report

“(2) The inquest heard that training on the effect of substance misuse on mental health conditions is not mandatory for all staff and would be of assistance when caring for patients such as Claire. ”

Is this part of a recurring concern?

Yes — Unreliable dual-diagnosis care pathways.

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

Pilot a caseload-management tool requiring enhanced-team cases to be discussed with clinical leads or team managers and recording contacts, attempted contacts and meetings.

Verbatim wording from the response

“To support the consistent implementation of FACT and the intensive and assertive approach to care, a caseload management tool is currently being piloted that will provide assurances that all service users within the Enhanced Team are discussed with a relevant clinical lead/team manager. This will ensure that clinicians receive additional case management support and ensure that all contacts, attempted contacts, and meetings are recorded within the notes, and that those who meet the criteria for benefiting from a more assertive approach are consistently identified and supported.”

Source location

Response from South West Yorkshire Partnership NHS Foundation Trust
Page 3 · response
Published 27 March 2025

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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

Provide co-occurring mental-health and substance-misuse training as an essential-to-role course for relevant staff, identifying completion through supervision or appraisal and recording it in training records.

Verbatim wording from the response

“Working with people with co-existing mental health problems and substance misuse issues has been included as a priority area of the mental health care group’s Learning Needs Analysis, which forms the basis of the training programme for all staff. Public Health England have made available an eLearning course – Better Care for people with co-occurring mental health and alcohol/drug use conditions, which has been made available to Trust staff. This is”

Source location

Response from South West Yorkshire Partnership NHS Foundation Trust
Page 3 · response
Published 27 March 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

Identify service users requiring intensive or assertive support and ensure they receive the appropriate level of care.

Verbatim wording from the response

“As part of this review process the Trust established a working group to work across the whole of the organisation. This review focused on provisions available to our Enhanced teams, who deliver care to those with the most complex needs in the community whose care can involve a variety of agencies. This work is on-going. Those requiring intensive and assertive support have been identified within our teams and we have ensured they have the correct level of care.”

Source location

Response from South West Yorkshire Partnership NHS Foundation Trust
Page 2 · response
Published 27 March 2025

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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

Conduct an organisation-wide review of intensive and assertive community support provision through an established working group.

Verbatim wording from the response

“In July 2024 NHS England (NHSE) began a review of the intensive and assertive community support available for those with serious mental health disorders, with Integrated Care Boards across the country reviewing current staffing provisions and numbers of service users who would access such services. NHSE are leading integrated care boards (ICBs) and other organisations in reviewing service delivery for people who require intensive and assertive community support, and we anticipate the publication of service standards for us to implement later this summer.”

Source location

Response from South West Yorkshire Partnership NHS Foundation Trust
Page 2 · response
Published 27 March 2025

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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 enhanced-team oversight of intensive and assertive care journeys, including clinical scrutiny of discharge planning, risk assessments and care plans.

Verbatim wording from the response

“The enhanced teams are now working to develop a greater understanding of those service users who require an intensive and assertive approach. This gives greater ability for teams and leaders to follow the care journey for these services users and add clinical scrutiny and assurance as part of discharge planning, to ensure safe oversight and discharge with up-to-date risk assessments and care plans.”

Source location

Response from South West Yorkshire Partnership NHS Foundation Trust
Page 2 · response
Published 27 March 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

Targeted training arrangements ensure staff who require substance-misuse training receive it, so mandatory training for all staff is not necessary.

Verbatim wording from the response

“Working with people with co-existing mental health problems and substance misuse issues has been included as a priority area of the mental health care group’s Learning Needs Analysis, which forms the basis of the training programme for all staff. Public Health England have made available an eLearning course – Better Care for people with co-occurring mental health and alcohol/drug use conditions, which has been made available to Trust staff. This is”

Source location

Response from South West Yorkshire Partnership NHS Foundation Trust
Page 3 · response
Published 27 March 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.1

  1. 1

    Work with partners to provide Trust mental-health nurses to the Integrated Co-occurring Needs initiative for people with co-existing mental-health and substance-misuse needs.

    Stated by South West Yorkshire Partnership Teaching NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 27 March 2025.

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 with partners to provide Trust mental-health nurses to the Integrated Co-occurring Needs initiative for people with co-existing mental-health and substance-misuse needs.

Verbatim wording from the response

“A new initiative of Integrated Co-occurring Needs (ICoN) is being set up in Barnsley that will bring together co-located workers from substance misuse services, mental health services and social care services to work with people with co-existing mental health and substance misuse issues. The Trust are currently working with partners to provide mental health nurses into the initiative. The model is operational and is being reviewed by local commissioners.”

Source location

Response from South West Yorkshire Partnership NHS Foundation Trust
Page 3 · response
Published 27 March 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