PFD report

Vincenzo Joseph Michael LIPPOLIS · Prevention of Future Deaths report

Pin Get email alerts Request correction

Issued 26 Oct 2022•Lincolnshire

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
3

Raised in this report

Recipients
3

Named on the report

Responses found
1

Of 3 recipients

Stated actions
0

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

Open published report

Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised3

  1. Premature closure of the mental health assessment case
    Part of recurring concern: Unsafe discharge, closure or withdrawal of mental health services
  2. Failure to undertake face-to-face assessment after recent suicide attempts
    Part of recurring concern: Failure to provide face-to-face mental health assessment when clinically indicatedPart of recurring concern: Failure to provide timely and competent mental health assessment after self-harm
  3. Failure to consider Mental Health Act admission criteria
    Part of recurring concern: Failure to ensure timely and appropriate Mental Health Act assessmentPart of recurring concern: Unsafe individualised treatment planning for acute mental health risk
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

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

  1. Position

    No systems or process changes are needed because the assessment followed recognised practice and decisions depend on individual circumstances.

    Stated by NAViGO Health and Social Care CICNo action considered necessaryThe respondent said that 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

Premature closure of the mental health assessment case

Wider context from the report

“In the NAVIGO report of 22nd October 2022 in response to the mother's request as to "why Vincenzo wasn't sectioned under the Mental Health Act after his detrimental (suicide) attempt on 16th October if only for observation" the SW replies "An admission to a mental health unit would not provide a therapeutic benefit as Vinny's social stressors would still be present in the future". The response does not seem to consider/reflect the admission criteria under s.2 or s.3 of the MHA. Please clarify the rational as the family believe an opportunity has been lost and a death could have been averted. In addition, the recommendation was for a face-to-face meeting with the deceased. Please explain why LPFT made only a telephone call on 17th October when if face to face observations and a more effective analysis had been undertaken particularly after the recent suicide attempts a more effective analysis could have been undertaken. As it was the case was closed on the same day. ”

Is this part of a recurring concern?

Yes — Unsafe discharge, closure or withdrawal of mental health services.

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 undertake face-to-face assessment after recent suicide attempts

Wider context from the report

“In the NAVIGO report of 22nd October 2022 in response to the mother's request as to "why Vincenzo wasn't sectioned under the Mental Health Act after his detrimental (suicide) attempt on 16th October if only for observation" the SW replies "An admission to a mental health unit would not provide a therapeutic benefit as Vinny's social stressors would still be present in the future". The response does not seem to consider/reflect the admission criteria under s.2 or s.3 of the MHA. Please clarify the rational as the family believe an opportunity has been lost and a death could have been averted. In addition, the recommendation was for a face-to-face meeting with the deceased. Please explain why LPFT made only a telephone call on 17th October when if face to face observations and a more effective analysis had been undertaken particularly after the recent suicide attempts a more effective analysis could have been undertaken. As it was the case was closed on the same day. ”

Is this part of a recurring concern?

Yes — Failure to provide face-to-face mental health assessment when clinically indicated; Failure to provide timely and competent mental health assessment after self-harm.

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 consider Mental Health Act admission criteria

Wider context from the report

“In the NAVIGO report of 22nd October 2022 in response to the mother's request as to "why Vincenzo wasn't sectioned under the Mental Health Act after his detrimental (suicide) attempt on 16th October if only for observation" the SW replies "An admission to a mental health unit would not provide a therapeutic benefit as Vinny's social stressors would still be present in the future". The response does not seem to consider/reflect the admission criteria under s.2 or s.3 of the MHA. Please clarify the rational as the family believe an opportunity has been lost and a death could have been averted. In addition, the recommendation was for a face-to-face meeting with the deceased. Please explain why LPFT made only a telephone call on 17th October when if face to face observations and a more effective analysis had been undertaken particularly after the recent suicide attempts a more effective analysis could have been undertaken. As it was the case was closed on the same day. ”

Is this part of a recurring concern?

Yes — Failure to ensure timely and appropriate Mental Health Act assessment; Unsafe individualised treatment planning for acute mental health risk.

Open source report

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

No systems or process changes are needed because the assessment followed recognised practice and decisions depend on individual circumstances.

Verbatim wording from the response

“11 NAViGO does not propose to take any action in relation to its systems or processes in response to the concern raised. The response above sets out the rationale for the decision. It followed an assessment of Mr Lippolis in line with nationally recognised practice by two experienced practitioners. The decision was based on Mr Lippolis’ responses and presentation at the time and the professional judgement of the practitioners. For the reasons given above there is, in NAViGO’s judgement, no change to systems or processes that need be made in order to avoid deaths in future. Decisions will always depend on the particular circumstances of each individual assessment.”

Source location

Response from NAViGO
Page 5 · response
Published 28 October 2022

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

Follow-up after hospital assessment was assigned to local LPFT services, with NAViGO recommending face-to-face contact.

Verbatim wording from the response

“6 The only observation made on the second concern is that NAViGO's Hospital Liaison Psychiatric Team contacted the relevant LPFT services after the assessment at the Hospital and requested a face to face follow-up with Vincenzo Joseph Michael Lippolis by his local services (as detailed in the written report of ████████, NAViGO Liaison Practitioner, dated 22 October 2022, provided to the Coroner).”

Source location

Response from NAViGO
Page 2 · response
Published 28 October 2022

Open published response
Back to top

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