PFD report

Ami Louise Mitchell · Prevention of Future Deaths report

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Issued 3 Nov 2022•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.

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Concerns
3

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 raised3

  1. Failure to admit a patient when admission is requested and clinically indicated
    Part of recurring concern: Failure to provide clinically indicated psychiatric admission
  2. Failure to make a formal diagnosis
  3. Failure to escalate management
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.3

  1. Action

    Ensure crisis care and treatment plans specify management escalation, including possible admission where appropriate.

    Stated by Avon and Wiltshire Mental Health Partnership NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 9 November 2022.
  2. Action

    Implement a diagnosis and formulation process based on best-practice guidance, recorded clinically and discussed with service users and carers.

    Stated by Avon and Wiltshire Mental Health Partnership NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 9 November 2022.
  3. Action

    Establish a Consultant medical lead for diagnosis in South Gloucestershire.

    Stated by Avon and Wiltshire Mental Health Partnership NHS TrustStated completedThe respondent said that this action was complete when they made their response on 9 November 2022.

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 admit a patient when admission is requested and clinically indicated

Wider context from the report

“Ms. Mitchell was under the care of AWP Trust with suicidal ideation from March to May 2022 until she hung herself on 31st May 2022. Throughout this period she presented regularly and persistently with a) delusions; b) auditory hallucinations (including command); c) visual hallucinations; d) intrusive thoughts of killing her partner and children; e) her and her family requesting admission Despite this a) No formal diagnosis was made; b) No escalation in management or admission took place. ”

Is this part of a recurring concern?

Yes — Failure to provide clinically indicated psychiatric admission.

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 make a formal diagnosis

Wider context from the report

“Ms. Mitchell was under the care of AWP Trust with suicidal ideation from March to May 2022 until she hung herself on 31st May 2022. Throughout this period she presented regularly and persistently with a) delusions; b) auditory hallucinations (including command); c) visual hallucinations; d) intrusive thoughts of killing her partner and children; e) her and her family requesting admission Despite this a) No formal diagnosis was made; b) No escalation in management or admission took place. ”

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 escalate management

Wider context from the report

“Ms. Mitchell was under the care of AWP Trust with suicidal ideation from March to May 2022 until she hung herself on 31st May 2022. Throughout this period she presented regularly and persistently with a) delusions; b) auditory hallucinations (including command); c) visual hallucinations; d) intrusive thoughts of killing her partner and children; e) her and her family requesting admission Despite this a) No formal diagnosis was made; b) No escalation in management or admission took place. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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

Ensure crisis care and treatment plans specify management escalation, including possible admission where appropriate.

Verbatim wording from the response

“The trust will achieve improvement in this area in part by the previous improvement around diagnosis, which will clearly support the escalation of a pathway. The Clinical lead for South Gloucestershire will also ensure that all care and treatment plans (Crisis Plans) have a clear expectation of management escalation including possible admission if relevant. This might include clarity on escalation to admission if deemed appropriate.”

Source location

Response from Avon and Wiltshire Mental Health Partnership
Page 2 · response
Published 9 November 2022

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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

Implement a diagnosis and formulation process based on best-practice guidance, recorded clinically and discussed with service users and carers.

Verbatim wording from the response

“Our improvement in this area includes the assurance that all service users receive a diagnosis and formulation from which care and treatment is informed by the NICE guidance appropriate for the diagnosis. In order to achieve this the trust must ensure the diagnosis or working diagnosis is clearly recorded in the clinical record, that the diagnosis or working diagnosis is discussed with the Service user and their family where appropriate and that there should be a protocol to adhere to where there is a difference of opinion.”

Source location

Response from Avon and Wiltshire Mental Health Partnership
Page 1 · response
Published 9 November 2022

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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

Establish a Consultant medical lead for diagnosis in South Gloucestershire.

Verbatim wording from the response

“We have ensured that there is now a Consultant medical lead for diagnosis in the area of South Gloucestershire and that this lead with senior support will work with the local team to put in place a diagnosis, which has been discussed informed by best practice guidelines and”

Source location

Response from Avon and Wiltshire Mental Health Partnership
Page 1 · response
Published 9 November 2022

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

    Audit progress on the diagnostic improvement actions at three and six months after implementation.

    Stated by Avon and Wiltshire Mental Health Partnership NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 9 November 2022.
  2. 2

    Develop five priority pathways covering complex emotional needs, dementia, dual diagnosis, neuro-development and psychosis.

    Stated by Avon and Wiltshire Mental Health Partnership NHS TrustStated completedThe respondent said that this action was complete when they made their response on 9 November 2022.
  3. 3

    Send an updated action plan six months later following completion and quality control.

    Stated by Avon and Wiltshire Mental Health Partnership NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 9 November 2022.
  4. 4

    Consult on the Trustwide Strategy to support wider improvement in pathway clarity.

    Stated by Avon and Wiltshire Mental Health Partnership NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 9 November 2022.

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

Audit progress on the diagnostic improvement actions at three and six months after implementation.

Verbatim wording from the response

“discussed with service user and their carer. We expect this progress on these actions to be audited in 3 and 6 months of the implementation for internal assurance.”

Source location

Response from Avon and Wiltshire Mental Health Partnership
Page 2 · response
Published 9 November 2022

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 five priority pathways covering complex emotional needs, dementia, dual diagnosis, neuro-development and psychosis.

Verbatim wording from the response

“The Clinical Strategy element of the Trustwide Strategy is underpinned by five principles which have been created in consultation with patients and service users, staff and the wider community. We have developed five priority pathways, Complex Emotional needs, Dementia, dual diagnosis, neuro-development, and psychosis. The future of psychosis services is an integrated pathway that is co-produced with service users and their carers, delivering timely interventions with appropriate length treatments, to enable recovery. We want to provide the best care, at the right time, through consistent services that are accessible by all communities.”

Source location

Response from Avon and Wiltshire Mental Health Partnership
Page 2 · response
Published 9 November 2022

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

Send an updated action plan six months later following completion and quality control.

Verbatim wording from the response

“We attach the updated action plan for your information and will be happy to send you an updated version six months from today, after completion and quality control.”

Source location

Response from Avon and Wiltshire Mental Health Partnership
Page 2 · response
Published 9 November 2022

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

Consult on the Trustwide Strategy to support wider improvement in pathway clarity.

Verbatim wording from the response

“I also believe that our ambitious Trustwide Strategy, currently out to consultation will direct a wider improvement in pathway clarity.”

Source location

Response from Avon and Wiltshire Mental Health Partnership
Page 2 · response
Published 9 November 2022

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