PFD report

Tamsin Rebecca Lianne GRUNDY · Prevention of Future Deaths report

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Issued 13 Mar 2019•Norfolk

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
2

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
1

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 provide continuity in the number of staff involved in care
    Part of recurring concern: Failure to provide continuity of care staffingPart of recurring concern: Failure to provide continuity of patient carePart of recurring concern: Unreliable crisis team care provision
  2. Failure to assign definitive, timed actions and named responsibility for identified care concerns
    Part of recurring concern: Failure to establish effective plans to address identified safety concerns
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.1

  1. Action

    Apply the national 39-point fidelity scale across the Trust to identify improvement areas and consistently match clinicians with patients using daily planning.

    Stated by Norfolk and Suffolk NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 11 June 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 CRHT cannot guarantee that service users will see a limited number of staff because intensive support requires flexible 24/7 staffing.

    Stated by Norfolk and Suffolk NHS Foundation TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.

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 provide continuity in the number of staff involved in care

Wider context from the report

“1.Miss Grundy repeatedly spoke about her concern about the number of people involved in her care, particularly from the Crisis Resolution Home Treatment Team. It is understood Miss Grundy saw 25 plus members of the Team in some 14 months. The evidence was that she found it difficult to relate to so many people, having to repeat the difficulties she was experiencing which she felt was adversely impacting on her mental health. It was not clear from the evidence that this issue was addressed during Miss Grundy's contact with the service. 2. This issue is referred to in the Serious Incident Requiring Investigation Report, having been raised by Miss Grundy’s family, but there is no definitive, timed action arising from it and no named person responsible for any such action. ”

Is this part of a recurring concern?

Yes — Failure to provide continuity of care staffing; Failure to provide continuity of patient care; Unreliable crisis team care provision.

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 assign definitive, timed actions and named responsibility for identified care concerns

Wider context from the report

“1.Miss Grundy repeatedly spoke about her concern about the number of people involved in her care, particularly from the Crisis Resolution Home Treatment Team. It is understood Miss Grundy saw 25 plus members of the Team in some 14 months. The evidence was that she found it difficult to relate to so many people, having to repeat the difficulties she was experiencing which she felt was adversely impacting on her mental health. It was not clear from the evidence that this issue was addressed during Miss Grundy's contact with the service. 2. This issue is referred to in the Serious Incident Requiring Investigation Report, having been raised by Miss Grundy’s family, but there is no definitive, timed action arising from it and no named person responsible for any such action. ”

Is this part of a recurring concern?

Yes — Failure to establish effective plans to address identified safety concerns.

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

Apply the national 39-point fidelity scale across the Trust to identify improvement areas and consistently match clinicians with patients using daily planning.

Verbatim wording from the response

“Notwithstanding this challenge, it was the expressed experience of Ms Grundy that having such numbers of staff involved made it difficult to form therapeutic relationships. To support continued development of the service provided, the CRHT team is using a national 39 point fidelity scale to help it reflect on current practices identifying areas of focus and improvement. One of the points refers directly to this matter and the team are working to apply this on a consistent basis, using daily planning to match clinicians with individual visits where a positive therapeutic relationship has developed. The scale is being used more widely across the Trust.”

Source location

2019-0088-Response-by-Norfolk-Suffolk-NHS-Trust
Page 1 · response
Published 11 June 2019

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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 CRHT cannot guarantee that service users will see a limited number of staff because intensive support requires flexible 24/7 staffing.

Verbatim wording from the response

“Ms Grundy was in contact with the Trust’s Youth Service since 2016. She was allocated a staff member whose role was to coordinate her care. This member played an important role in forming a therapeutic relationship with the service user, working together to implement plans to help respond to the individual’s needs. There are occasions where an individual’s need changes requiring a period of more intensive support which is provided by the Trust’s acute services. The CRHT provide intensive periods of support in the community for short periods, supplementing the care provided by the community team. This means the team have to be flexible and adaptable in approach requiring staff to work over a 24 hour period, seven days per week. Appointments with users may range from multiple contacts in a day to every few days.”

Source location

2019-0088-Response-by-Norfolk-Suffolk-NHS-Trust
Page 1 · response
Published 11 June 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