PFD report

Emma Kate DORMAN · Prevention of Future Deaths report

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Issued 11 Mar 2021•West Yorkshire, Western Division

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
10

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. Lack of psychologist input on the ward
  2. Failure to ensure clinical management and leave decisions are made by responsible clinical staff
    Part of recurring concern: Unsafe clinical responsibility for mental health leave and detention decisions
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.9

  1. Action

    Monitor inpatient staff understanding of patient-flow procedures and responsibilities through the Matrons’ monthly checklist.

    Stated by South West Yorkshire Partnership Teaching NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 12 March 2021.
  2. Action

    Use redesigned, flexible-working and job-sharing approaches to attract applicants for Clinical Psychologist posts.

    Stated by South West Yorkshire Partnership Teaching NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 12 March 2021.
  3. Action

    Provide inpatient staff with the Patient Flow Procedure and information clarifying patient-flow roles and responsibilities.

    Stated by South West Yorkshire Partnership Teaching NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 12 March 2021.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.2

  1. Position

    National shortages of Clinical Psychologists constrain the Trust’s ability to appoint to the vacant Ward 18 psychology post.

    Stated by South West Yorkshire Partnership Teaching 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

Lack of psychologist input on the ward

Wider context from the report

“2. That there was no psychologist input on the ward, which had persisted for over three years prior to this incident. The only steps taken to alleviate this vacancy was to re-advertise the same post with the same level of remuneration. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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 ensure clinical management and leave decisions are made by responsible clinical staff

Wider context from the report

“1. That the decision of leave was dominated by the non-clinical team through the Bed Manager and clinical staff felt they could not object. The draft amended clarification still enable those not directly responsible for patient care to effect clinical management of the patient. ”

Is this part of a recurring concern?

Yes — Unsafe clinical responsibility for mental health leave and detention decisions.

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

Monitor inpatient staff understanding of patient-flow procedures and responsibilities through the Matrons’ monthly checklist.

Verbatim wording from the response

“I can confirm that inpatient staff understanding of the procedure, and the responsibilities of those involved in the patient flow process (including that of ward staff and of patient flow staff) will be monitored through the Matron’s monthly checklist.”

Source location

2021-0071-Response-from-South-West-Yorkshire-Partnership-NHS-Foundation-Trust-Redacted
Page 2 · response
Published 12 March 2021

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

Use redesigned, flexible-working and job-sharing approaches to attract applicants for Clinical Psychologist posts.

Verbatim wording from the response

“The Trust has taken various approaches to attract applicants to such posts, including redesign, flexible working and job sharing, but sadly the national shortage from Clinical Psychologists continues to impact on the Trust’s ability to appoint to these posts.”

Source location

2021-0071-Response-from-South-West-Yorkshire-Partnership-NHS-Foundation-Trust-Redacted
Page 2 · response
Published 12 March 2021

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

Provide inpatient staff with the Patient Flow Procedure and information clarifying patient-flow roles and responsibilities.

Verbatim wording from the response

“In light of the above and your concerns, the Trust have provided all staff within the Inpatient setting a copy of the current Patient Flow Procedure, accompanied with information specifically detailing theirs and their colleague’s roles as part of the patient flow process.”

Source location

2021-0071-Response-from-South-West-Yorkshire-Partnership-NHS-Foundation-Trust-Redacted
Page 2 · response
Published 12 March 2021

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

Provide interim in-reach psychology support to Ward 18 through a Clinical Psychologist from the CORE community team.

Verbatim wording from the response

“In the interim and until we have recruited to the above psychology post a Clinical Psychologist working within the CORE community team will provide in-reach psychology support to Ward 18.”

Source location

2021-0071-Response-from-South-West-Yorkshire-Partnership-NHS-Foundation-Trust-Redacted
Page 3 · response
Published 12 March 2021

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 the Ward 18 part-time Psychologist post into Psychology services based within Community Services.

Verbatim wording from the response

“As per ████████ addendum statement dated 12th February 2021, subsequent to the six failed attempts to recruit a part time Psychologist to Ward 18, an agreement was made for the Ward 18 part time Psychologist post to be incorporated into the Psychology services that are based within Community Services.”

Source location

2021-0071-Response-from-South-West-Yorkshire-Partnership-NHS-Foundation-Trust-Redacted
Page 3 · response
Published 12 March 2021

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

Review the skill mix of existing vacant psychology posts to support consideration of a funding-related banding increase.

Verbatim wording from the response

“The Community Services are currently reviewing the skill-mix for existing vacant psychology posts in order to provide funding for a banding increase, and subsequent to this the Trust’s Psychological Therapy Lead will review and update the Job Description and Person Specification for the role. Once the updated Job Description and Person Specification has been drafted, it will be submitted to the Trust’s Agenda for Change banding review panel. If approved by the panel the role will be advertised. We anticipate this process will conclude in June 2021.”

Source location

2021-0071-Response-from-South-West-Yorkshire-Partnership-NHS-Foundation-Trust-Redacted
Page 3 · response
Published 12 March 2021

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

Review and update the psychology role’s Job Description and Person Specification after the skill-mix review.

Verbatim wording from the response

“The Community Services are currently reviewing the skill-mix for existing vacant psychology posts in order to provide funding for a banding increase, and subsequent to this the Trust’s Psychological Therapy Lead will review and update the Job Description and Person Specification for the role. Once the updated Job Description and Person Specification has been drafted, it will be submitted to the Trust’s Agenda for Change banding review panel. If approved by the panel the role will be advertised. We anticipate this process will conclude in June 2021.”

Source location

2021-0071-Response-from-South-West-Yorkshire-Partnership-NHS-Foundation-Trust-Redacted
Page 3 · response
Published 12 March 2021

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

Submit the updated psychology role documentation to the Agenda for Change banding review panel.

Verbatim wording from the response

“The Community Services are currently reviewing the skill-mix for existing vacant psychology posts in order to provide funding for a banding increase, and subsequent to this the Trust’s Psychological Therapy Lead will review and update the Job Description and Person Specification for the role. Once the updated Job Description and Person Specification has been drafted, it will be submitted to the Trust’s Agenda for Change banding review panel. If approved by the panel the role will be advertised. We anticipate this process will conclude in June 2021.”

Source location

2021-0071-Response-from-South-West-Yorkshire-Partnership-NHS-Foundation-Trust-Redacted
Page 3 · response
Published 12 March 2021

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

Employ several Matrons with clinical and operational responsibility for inpatient wards.

Verbatim wording from the response

“The Trust notes your continued concern over the decision making by Registered Clinical Staff (Bed Flow Managers) who are not always involved at ward level. Over the past 2 years the Trust has undertaken an extensive review of its clinical structures and has employed several Matrons within its Inpatient settings. The Matrons are clinically and operationally responsible for each Ward”

Source location

2021-0071-Response-from-South-West-Yorkshire-Partnership-NHS-Foundation-Trust-Redacted
Page 1 · response
Published 12 March 2021

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

National shortages of Clinical Psychologists constrain the Trust’s ability to appoint to the vacant Ward 18 psychology post.

Verbatim wording from the response

“Unfortunately, the Trust has had a high vacancy rate for Clinical Psychologist posts over the last couple of years as a result of the national shortages surrounding the profession.”

Source location

2021-0071-Response-from-South-West-Yorkshire-Partnership-NHS-Foundation-Trust-Redacted
Page 2 · response
Published 12 March 2021

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

Existing clinical patient-flow procedures, ward oversight and escalation arrangements are considered sufficient to support clinically led admission decisions.

Verbatim wording from the response

“The Trust has a Patient Flow Procedure that provides a framework for staff relating to activities around pre-admission, bed allocation and management processes, the inpatient stay and discharge of service users. The procedure is used to support decisions and management of service users from the point when they require access to an inpatient bed, through to their discharge from a ward. The Patient Flow (Bed Management) Team are involved in the application of the patient flow process across the Trust by working in partnership with the Inpatient services. The Patient Flow Team is a clinically led service.”

Source location

2021-0071-Response-from-South-West-Yorkshire-Partnership-NHS-Foundation-Trust-Redacted
Page 1 · response
Published 12 March 2021

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

    Arrange retired Clinical Psychologists to support Psychology services during increased demand.

    Stated by South West Yorkshire Partnership Teaching NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 12 March 2021.

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

Arrange retired Clinical Psychologists to support Psychology services during increased demand.

Verbatim wording from the response

“The Trust successfully arranged for retired Clinical Psychologists to support its Psychology services to respond to increased demand as a result of the on-going COVID-19 pandemic, but unfortunately we were unable to attract someone to temporarily fill the Ward 18 vacant post.”

Source location

2021-0071-Response-from-South-West-Yorkshire-Partnership-NHS-Foundation-Trust-Redacted
Page 3 · response
Published 12 March 2021

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