PFD report

Stephen LINDSAY · Prevention of Future Deaths report

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Issued 1 Aug 2024•Cumbria

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
2

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 to provide mental health support to people with terminal illness
  2. Lack of clear responsibility for providing mental health treatment to people with terminal illness
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.2

  1. Action

    Hold a reflective learning event with those involved in Mr Lindsay’s care to identify opportunities to improve seamless, responsive and supportive terminal-illness care.

    Stated by NHS North East and North Cumbria Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 8 August 2024.
  2. Action

    Review Mr Lindsay’s patient journey from before diagnosis through his death to identify care and treatment issues.

    Stated by NHS North East and North Cumbria Integrated Care BoardStated completedThe respondent said that this action was complete when they made their response on 8 August 2024.

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 provide mental health support to people with terminal illness

Wider context from the report

“(1) I am concerned that providing treatment for Mr Lindsay's mental health was passed between several teams, with none of them being willing to accept that it fell within the ambit of services they had been commissioned to provide. I am concerned that there is a risk that in future cases mental health support will not be provided to those suffering from terminal illness and that this may lead to other patients experiencing crisis and attempting to end their lives. I consider that the lack of clarity as to the responsibility for providing such care may cause further deaths. (2) (3) ”

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 clear responsibility for providing mental health treatment to people with terminal illness

Wider context from the report

“(1) I am concerned that providing treatment for Mr Lindsay's mental health was passed between several teams, with none of them being willing to accept that it fell within the ambit of services they had been commissioned to provide. I am concerned that there is a risk that in future cases mental health support will not be provided to those suffering from terminal illness and that this may lead to other patients experiencing crisis and attempting to end their lives. I consider that the lack of clarity as to the responsibility for providing such care may cause further deaths. (2) (3) ”

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

Hold a reflective learning event with those involved in Mr Lindsay’s care to identify opportunities to improve seamless, responsive and supportive terminal-illness care.

Verbatim wording from the response

“To further address your concern, the ICB will also be holding a reflective learning event with those involved in Mr Lindsay's care and treatment. This will enable the teams to reflect, identify and explore further opportunities to improve patients experience of care and to ensure that there are no unforeseen barriers in ensuring that any patient suffering a terminal illness receives seamless, responsive and supportive care. We would be happy to share the outcome of this event with Mr Lindsay's family and yourself.”

Source location

Response from NENC ICB
Page 2 · response
Published 8 August 2024

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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

Review Mr Lindsay’s patient journey from before diagnosis through his death to identify care and treatment issues.

Verbatim wording from the response

“The ICB have undertaken a review of Mr Lindsay's patient journey from the months prior to his diagnosis with metastatic Oesophageal Cancer up until his date of death.”

Source location

Response from NENC ICB
Page 1 · response
Published 8 August 2024

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