PFD report

Drew Howe · Prevention of Future Deaths report

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Issued 15 May 2023•Manchester South

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
4

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
12

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 raised4

  1. Failure to explore access to services from the patient’s perspective in investigations
  2. Lack of meaningful critical analysis in investigations
  3. Failure to consider the full extent of contacts with mental health services in investigations
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 referral-related information, including assessments, is shared between services through team, supervision and operational meetings.

    Stated by Pennine Care NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 17 May 2023.
  2. Action

    Explore adding a digital prompt to electronic patient records to support inclusion of referral information.

    Stated by Pennine Care NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 17 May 2023.
  3. Action

    Share Trust-wide learning, including themes concerning military veterans’ experiences navigating mental health services.

    Stated by Pennine Care NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 17 May 2023.

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 explore access to services from the patient’s perspective in investigations

Wider context from the report

“The Trust’s own investigation into events leading to Mr Howe’s death did not consider the full extent of his contacts with mental health services, lacked any meaningful degree of critical analysis of events, and omitted to seek to explore fundamental issues such as access to services from the patient’s perspective. As a consequence, it is a matter of concern that the Trust has not taken the opportunity to derive all available learning from Mr Howe’s death. ”

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

Lack of meaningful critical analysis in investigations

Wider context from the report

“The Trust’s own investigation into events leading to Mr Howe’s death did not consider the full extent of his contacts with mental health services, lacked any meaningful degree of critical analysis of events, and omitted to seek to explore fundamental issues such as access to services from the patient’s perspective. As a consequence, it is a matter of concern that the Trust has not taken the opportunity to derive all available learning from Mr Howe’s death. ”

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 consider the full extent of contacts with mental health services in investigations

Wider context from the report

“The Trust’s own investigation into events leading to Mr Howe’s death did not consider the full extent of his contacts with mental health services, lacked any meaningful degree of critical analysis of events, and omitted to seek to explore fundamental issues such as access to services from the patient’s perspective. As a consequence, it is a matter of concern that the Trust has not taken the opportunity to derive all available learning from Mr Howe’s death. ”

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 derive all available learning from deaths

Wider context from the report

“The Trust’s own investigation into events leading to Mr Howe’s death did not consider the full extent of his contacts with mental health services, lacked any meaningful degree of critical analysis of events, and omitted to seek to explore fundamental issues such as access to services from the patient’s perspective. As a consequence, it is a matter of concern that the Trust has not taken the opportunity to derive all available learning from Mr Howe’s death. ”

Is this part of a recurring concern?

Yes — Failure to learn from deaths through systematic review.

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 referral-related information, including assessments, is shared between services through team, supervision and operational meetings.

Verbatim wording from the response

“• Teams to ensure that information, including assessment information is shared between services when referrals are made – to be discussed at team meetings, supervision, operational meetings. Trust to also explore if a digital prompt can be added to our Electronic Patient records to further support the inclusion of information when a referral is made.”

Source location

Response from Pennine Care NHS Foundation Trust
Page 4 · response
Published 17 May 2023

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

Explore adding a digital prompt to electronic patient records to support inclusion of referral information.

Verbatim wording from the response

“• Teams to ensure that information, including assessment information is shared between services when referrals are made – to be discussed at team meetings, supervision, operational meetings. Trust to also explore if a digital prompt can be added to our Electronic Patient records to further support the inclusion of information when a referral is made.”

Source location

Response from Pennine Care NHS Foundation Trust
Page 4 · response
Published 17 May 2023

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

Share Trust-wide learning, including themes concerning military veterans’ experiences navigating mental health services.

Verbatim wording from the response

“• Ensure trust wide learning including exploring themes around death by suicide of Military veterans in mental health services given concerns relating to the perspective of the client in navigating mental health services.”

Source location

Response from Pennine Care NHS Foundation Trust
Page 3 · response
Published 17 May 2023

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.9

  1. 1

    Pursue TILS Raising Awareness sessions.

    Stated by Pennine Care NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 17 May 2023.
  2. 2

    Develop trauma-understanding training and seek support from the GM Resilience Hub or Military Veteran Service.

    Stated by Pennine Care NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 17 May 2023.
  3. 3

    Revise the Rapid Initial Review template to explain the review’s purpose.

    Stated by Pennine Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 17 May 2023.
  4. 4

    Conduct team case reflection focused on recognising risk and trauma’s impact on risk formulation.

    Stated by Pennine Care NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 17 May 2023.
  5. 5

    Consider investigators’ suitability and circumstances to determine required support and whether reassignment is appropriate.

    Stated by Pennine Care NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 17 May 2023.
  6. 6

    Develop a support guide for staff completing Rapid Initial Reviews.

    Stated by Pennine Care NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 17 May 2023.
  7. 7

    Review the Trust-wide 72-hour Rapid Initial Review process to ensure intended compliance and early identification of further investigation.

    Stated by Pennine Care NHS Foundation TrustStatus unclearThe respondent did not make the status of this action clear when they made their response on 17 May 2023.
  8. 8

    Review and develop the training offer for staff completing investigations.

    Stated by Pennine Care NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 17 May 2023.
  9. 9

    Continue supportive check-ins with investigation authors, emphasising the 72-hour timeframe.

    Stated by Pennine Care NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 17 May 2023.

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

Pursue TILS Raising Awareness sessions.

Verbatim wording from the response

“• Pursue Raising Awareness sessions as offered by the TILS service.”

Source location

Response from Pennine Care NHS Foundation Trust
Page 3 · response
Published 17 May 2023

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 trauma-understanding training and seek support from the GM Resilience Hub or Military Veteran Service.

Verbatim wording from the response

“• Understanding trauma – exploring the training the training offer for staff. This includes the current training being developed within the Trust around understanding Trauma, as well as seeking support from the GM Resilience Hub or Military Veteran Service (MVS).”

Source location

Response from Pennine Care NHS Foundation Trust
Page 4 · response
Published 17 May 2023

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

Revise the Rapid Initial Review template to explain the review’s purpose.

Verbatim wording from the response

“• Trust wide review of the learning in this case from a process perspective. The Rapid Initial Review template has been reviewed to include a brief explanation of the purpose of the review – detailed on the front page of the report.”

Source location

Response from Pennine Care NHS Foundation Trust
Page 2 · response
Published 17 May 2023

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

Conduct team case reflection focused on recognising risk and trauma’s impact on risk formulation.

Verbatim wording from the response

“• Case reflection with teams involved with a focus on recognising risk and the impact of trauma on risk formulation.”

Source location

Response from Pennine Care NHS Foundation Trust
Page 3 · response
Published 17 May 2023

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

Consider investigators’ suitability and circumstances to determine required support and whether reassignment is appropriate.

Verbatim wording from the response

“• In addition to the above, the Quality team will give further consideration to the person identified to complete the Rapid Initial Review and any extenuating circumstances. This will allow for consideration of additional support required from the outset and plan for any change to level of support required. This may also take into consideration if the Rapid Initial review would be best placed to be completed by another identified professional.”

Source location

Response from Pennine Care NHS Foundation Trust
Page 3 · response
Published 17 May 2023

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 support guide for staff completing Rapid Initial Reviews.

Verbatim wording from the response

“• A brief support guide for completing a Rapid Initial Review to be completed to support authors – this is being led by the Head of Patient Safety for the trust.”

Source location

Response from Pennine Care NHS Foundation Trust
Page 2 · response
Published 17 May 2023

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 Trust-wide 72-hour Rapid Initial Review process to ensure intended compliance and early identification of further investigation.

Verbatim wording from the response

“• A Trust wide review of the 72-hour review (Rapid Initial Review) process to ensure that it is being followed as originally intended with early identification of further action and investigation required. Appendix1.”

Source location

Response from Pennine Care NHS Foundation Trust
Page 2 · response
Published 17 May 2023

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 develop the training offer for staff completing investigations.

Verbatim wording from the response

“• The trust is also reviewing the training offer for authors completing investigations with a view to developing this to support staff.”

Source location

Response from Pennine Care NHS Foundation Trust
Page 2 · response
Published 17 May 2023

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

Continue supportive check-ins with investigation authors, emphasising the 72-hour timeframe.

Verbatim wording from the response

“• Supportive check-ins with authors of Investigations are offered by the Quality team, these will continue with an emphasis on time frame as detailed in the 72-hour process.”

Source location

Response from Pennine Care NHS Foundation Trust
Page 3 · response
Published 17 May 2023

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