PFD report

Michael Brendan O’SULLIVAN · Prevention of Future Deaths report

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Issued 13 Jan 2014•Inner North 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
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
7

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 of ultimate decision makers to obtain and review treating clinicians’ reports
  2. Failure of assessing doctors to take into account treating doctors’ views
    Part of recurring concern: Failure to incorporate relevant collateral and professional views into clinical assessment
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

    Keep processes for collecting further medical evidence under constant review and improve them where possible.

    Stated by Department for Work and PensionsStated in progressThe respondent said that this action was in progress when they made their response on 13 January 2014.

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

  1. Position

    Ongoing litigation limits comment on universal further medical evidence, and an interim judgment found that requiring this change was not reasonable.

    Stated by Department for Work and PensionsUnable 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 of ultimate decision makers to obtain and review treating clinicians’ reports

Wider context from the report

“The DWP assessing doctor (who saw Mr O’Sullivan for a 90 minute consultation) did not take into account the views of any of Mr O’Sullivan’s treating doctors, saying that the ultimate decision maker would do that. However, the ultimate decision maker (who is not, I understand, medically qualified) did not request and so did not see any reports or letters from Mr O’Sullivan’s general practitioner (who had assessed him as being unfit for work), his psychiatrist or his clinical psychologist. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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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 of assessing doctors to take into account treating doctors’ views

Wider context from the report

“The DWP assessing doctor (who saw Mr O’Sullivan for a 90 minute consultation) did not take into account the views of any of Mr O’Sullivan’s treating doctors, saying that the ultimate decision maker would do that. However, the ultimate decision maker (who is not, I understand, medically qualified) did not request and so did not see any reports or letters from Mr O’Sullivan’s general practitioner (who had assessed him as being unfit for work), his psychiatrist or his clinical psychologist. ”

Is this part of a recurring concern?

Yes — Failure to incorporate relevant collateral and professional views into clinical assessment.

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

Keep processes for collecting further medical evidence under constant review and improve them where possible.

Verbatim wording from the response

“71. We, of course, remain committed to keeping our processes for collecting further evidence under constant review and to improving these processes where possible. It remains important to retain a balance between the added value of further evidence in any claim for ESA and time demands on GPs and other healthcare professionals.”

Source location

2014-0012-Response-by-DWP
Page 15 · response
Published 13 January 2014

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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

Ongoing litigation limits comment on universal further medical evidence, and an interim judgment found that requiring this change was not reasonable.

Verbatim wording from the response

“68. It has been routinely suggested that DWP should obtain medical reports for individuals with a mental illness, learning disability or related condition who are beginning the WCA process.”

Source location

2014-0012-Response-by-DWP
Page 14 · response
Published 13 January 2014

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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 existing division between Atos-trained healthcare professionals and GPs is retained because each has a distinct role and GPs generally lack relevant assessment expertise.

Verbatim wording from the response

“70. This issue of further medical evidence has also been considered as part of the independent review process. The distinction drawn between the respective functions of HCPs and GPs is a key element of the policy intent behind the WCA, and is supported by the British Medical Association. In its response to Professor Harrington’s call for evidence for his third independent review, the BMA said:”

Source location

2014-0012-Response-by-DWP
Page 14 · response
Published 13 January 2014

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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.6

  1. 1

    Implement recommendations from the first three independent Work Capability Assessment reviews.

    Stated by Department for Work and PensionsStated in progressThe respondent said that this action was in progress when they made their response on 13 January 2014.
  2. 2

    Develop guidance for healthcare professionals on assessing suicidal risk.

    Stated by Department for Work and PensionsStated completedThe respondent said that this action was complete when they made their response on 13 January 2014.
  3. 3

    Monitor policies concerning assessment of people with mental health problems.

    Stated by Department for Work and PensionsStated in progressThe respondent said that this action was in progress when they made their response on 13 January 2014.
  4. 4

    Consider practical improvements to the Work Capability Assessment in light of Evidence Based Review findings.

    Stated by Department for Work and PensionsStated in progressThe respondent said that this action was in progress when they made their response on 13 January 2014.
  5. 5

    Issue staff a reminder about guidance for handling suicidal ideation.

    Stated by Department for Work and PensionsStated plannedThe respondent said that this action was planned when they made their response on 13 January 2014.
  6. 6

    Roll out suicidal-risk assessment guidance nationally for healthcare professionals.

    Stated by Department for Work and PensionsStated plannedThe respondent said that this action was planned when they made their response on 13 January 2014.

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 recommendations from the first three independent Work Capability Assessment reviews.

Verbatim wording from the response

“62. The first such review of this kind found that generally the WCA was accurately identifying individuals for their entitlement to benefit but it also made recommendations where improvements to the assessment could be made. Recommendations from the reviews to date have included simplifying much of the language used throughout the assessment process, making greater provision for individuals awaiting chemotherapy treatment and widening the criteria for support in relation to people’s mental function. The Government has implemented, or is in the process of implementing, over 50 recommendations from the first three reviews. The fourth independent review was published in December 2013, and the Department has accepted or accepted with certain caveats all but one of the 32 that fall within its scope.”

Source location

2014-0012-Response-by-DWP
Page 13 · response
Published 13 January 2014

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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 guidance for healthcare professionals on assessing suicidal risk.

Verbatim wording from the response

“46. As the risk of suicide is never easy to predict, we are committed to ensuring that all HCPs undertaking assessments are suitably trained and we have been working to continually enhance the training that HCPs receive in this area. We have worked with expert Psychiatrists to develop guidance for HCPs on assessing suicidal risk. An initial trial of the guidance proved positive and we are now looking to roll it out nationally.”

Source location

2014-0012-Response-by-DWP
Page 10 · response
Published 13 January 2014

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

Monitor policies concerning assessment of people with mental health problems.

Verbatim wording from the response

“73. We have noted the issues in this case and will continue to monitor our policies around assessment of people with mental health problems while we await the outcome of related litigation (discussed at paragraph 68). We will also issue a reminder to staff about the guidance related to suicidal ideation that has been described in this report.”

Source location

2014-0012-Response-by-DWP
Page 15 · response
Published 13 January 2014

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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

Consider practical improvements to the Work Capability Assessment in light of Evidence Based Review findings.

Verbatim wording from the response

“66. The Department has recently undertaken a systematic study – Evidence Based Review of the WCA – to examine in detail how the WCA descriptors compared with alternative assessment proposals that were developed by a group of disability representative organisations, including leading mental health charities.¹⁴”

Source location

2014-0012-Response-by-DWP
Page 14 · response
Published 13 January 2014

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

Issue staff a reminder about guidance for handling suicidal ideation.

Verbatim wording from the response

“2. The Department has a number of safeguards for Employment and Support Allowance claimants with mental health problems. This includes a clear policy that further medical evidence in cases where claimants report suicidal ideation in their claim forms which regrettably was not followed in this case. We will issue a reminder to staff about the relevant guidance.”

Source location

2014-0012-Response-by-DWP
Page 1 · response
Published 13 January 2014

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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

Roll out suicidal-risk assessment guidance nationally for healthcare professionals.

Verbatim wording from the response

“46. As the risk of suicide is never easy to predict, we are committed to ensuring that all HCPs undertaking assessments are suitably trained and we have been working to continually enhance the training that HCPs receive in this area. We have worked with expert Psychiatrists to develop guidance for HCPs on assessing suicidal risk. An initial trial of the guidance proved positive and we are now looking to roll it out nationally.”

Source location

2014-0012-Response-by-DWP
Page 10 · response
Published 13 January 2014

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