PFD report

Sian Leigh ARMSTRONG · Prevention of Future Deaths report

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Issued 21 Jan 2015•Avon

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
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 raised1

  1. Delays in providing CBT to children assessed as needing it
    Part of recurring concern: Excessive waiting times for NHS mental health servicesPart of recurring concern: Unreliable access to talking therapies
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

    Involve Off the Record staff in CAMHS intake meetings and finalise governance arrangements for cross-organisational working.

    Stated by Bristol NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 21 January 2015.

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

Delays in providing CBT to children assessed as needing it

Wider context from the report

“1. There was a delay in Sian receiving CBT which she was assessed as requiring. ”

Is this part of a recurring concern?

Yes — Excessive waiting times for NHS mental health services; Unreliable access to talking therapies.

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

Involve Off the Record staff in CAMHS intake meetings and finalise governance arrangements for cross-organisational working.

Verbatim wording from the response

“• Bristol and South Gloucestershire Clinical Commissioning Groups (CCG) directly commission Tier 2 services from Off the Record. We are working with our two CCG’s, to involve Off the Record in our CAMHS intake meetings”

Source location

2015-0019-North-Bristol-NHS-Trust
Page 1 · response
Published 21 January 2015

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.4

  1. 1

    Develop a crisis intervention team model for young people who are difficult to engage and self-harm, with implementation planned for June 2015.

    Stated by Bristol NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 21 January 2015.
  2. 2

    Implement an assertive outreach project for hard-to-reach young people following Community Children’s Health Partnership re-procurement in 2017.

    Stated by Bristol NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 21 January 2015.
  3. 3

    Introduce correspondence guidance inviting parents and carers to contact CAMHS and ensuring their concerns are heard and considered.

    Stated by Bristol NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 21 January 2015.
  4. 4

    Develop a protocol to guide CAMHS clinicians supporting young people who do not want to engage.

    Stated by Bristol NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 21 January 2015.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.2

  1. 1

    Bristol Clinical Commissioning Group is responsible for scoping and recommending the crisis intervention team model.

    Stated by Bristol NHS Foundation TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
  2. 2

    Clinical commissioning groups directly commission Tier 2 services from Off the Record.

    Stated by Bristol NHS Foundation TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.

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 a crisis intervention team model for young people who are difficult to engage and self-harm, with implementation planned for June 2015.

Verbatim wording from the response

“• For young people who are hard to engage we have been working with the Bristol Clinical Commissioning Group (CCG) to develop a Crisis intervention team model. A Project Lead has been appointed by Bristol CCG and is currently scoping local services in order to recommend a best model of practice. This will improve the response to young people who self-harm. The crisis intervention team is currently being planned for implementation in June 2015. An assertive outreach project is planned to deliver services to hard to reach young people for example those with forensic difficulties and substance misuse. The implementation of this will take place following the re-procurement of the Community Children’s Health Partnership in 2017.”

Source location

2015-0019-North-Bristol-NHS-Trust
Page 2 · response
Published 21 January 2015

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 an assertive outreach project for hard-to-reach young people following Community Children’s Health Partnership re-procurement in 2017.

Verbatim wording from the response

“• For young people who are hard to engage we have been working with the Bristol Clinical Commissioning Group (CCG) to develop a Crisis intervention team model. A Project Lead has been appointed by Bristol CCG and is currently scoping local services in order to recommend a best model of practice. This will improve the response to young people who self-harm. The crisis intervention team is currently being planned for implementation in June 2015. An assertive outreach project is planned to deliver services to hard to reach young people for example those with forensic difficulties and substance misuse. The implementation of this will take place following the re-procurement of the Community Children’s Health Partnership in 2017.”

Source location

2015-0019-North-Bristol-NHS-Trust
Page 2 · response
Published 21 January 2015

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 correspondence guidance inviting parents and carers to contact CAMHS and ensuring their concerns are heard and considered.

Verbatim wording from the response

“• Whilst we have to be cognisant of young people’s consent and competency in relation to involving parents and carers, we will invite parents to contact CAMHS if they have ongoing and or additional concerns. We will listen to them and consider their concerns. This principle will be introduced into all correspondence with families / carers and young people from 1 April 2015.”

Source location

2015-0019-North-Bristol-NHS-Trust
Page 1 · response
Published 21 January 2015

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

Develop a protocol to guide CAMHS clinicians supporting young people who do not want to engage.

Verbatim wording from the response

“• We have developed a new protocol to assist CAMHS clinicians who are faced with young people do not want to engage. (attached)”

Source location

2015-0019-North-Bristol-NHS-Trust
Page 1 · response
Published 21 January 2015

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

Bristol Clinical Commissioning Group is responsible for scoping and recommending the crisis intervention team model.

Verbatim wording from the response

“• For young people who are hard to engage we have been working with the Bristol Clinical Commissioning Group (CCG) to develop a Crisis intervention team model. A Project Lead has been appointed by Bristol CCG and is currently scoping local services in order to recommend a best model of practice. This will improve the response to young people who self-harm. The crisis intervention team is currently being planned for implementation in June 2015. An assertive outreach project is planned to deliver services to hard to reach young people for example those with forensic difficulties and substance misuse. The implementation of this will take place following the re-procurement of the Community Children’s Health Partnership in 2017.”

Source location

2015-0019-North-Bristol-NHS-Trust
Page 2 · response
Published 21 January 2015

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

Clinical commissioning groups directly commission Tier 2 services from Off the Record.

Verbatim wording from the response

“• Bristol and South Gloucestershire Clinical Commissioning Groups (CCG) directly commission Tier 2 services from Off the Record. We are working with our two CCG’s, to involve Off the Record in our CAMHS intake meetings”

Source location

2015-0019-North-Bristol-NHS-Trust
Page 1 · response
Published 21 January 2015

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