PFD report

Gary Richards · Prevention of Future Deaths report

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Issued 9 May 2014•Inner South 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
6

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 raised6

  1. Failure to complete identified clinical pathway and interagency service improvements
    Part of recurring concern: Failure to implement identified safety actions
  2. Lack of clarity of responsibility for risk assessment
    Part of recurring concern: Unclear accountability for safety risk assessments
  3. Failure to ensure reliable communication pathways for follow-up
    Part of recurring concern: Failure to maintain contact with vulnerable people after initial engagementPart of recurring concern: Failure to maintain follow-up of patients who disengage from carePart of recurring concern: Unreliable arrangement and communication of patient appointments and follow-up
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

    Remind staff to record risk assessments in the correct electronic patient-record section.

    Stated by South London and Maudsley NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 9 May 2014.
  2. Action

    Secure £250,000 funding to pilot a mental-health-specific homeless project linked to an established homeless support scheme.

    Stated by South London and Maudsley NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 9 May 2014.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.5

  1. Position

    Follow-up was attempted using the patient’s recorded telephone number and messages through A&E, rather than wholly failing through absent communication pathways.

    Stated by South London and Maudsley NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

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 complete identified clinical pathway and interagency service improvements

Wider context from the report

“(2) After discharge in May, he was not followed up, as there was no address and his mobile phone number was not recorded. After attendance in June, again there was a failure to contact him for follow up, reported to be due to a phone failure. The failure to ensure reliable communication pathways for follow up is a potential risk for vulnerable patients. (3) The Serious Untoward Incident Report (Acute Mental Health Comprehensive Level Two Report, 10th October 2012) found seven areas of concern and service delivery problems, including weaknesses in risk assessment and recognition of suicide plan, lack of clarity of responsibility for risk assessment, inadequate 7 day follow up and communications with GP and problems in support as no mental illness. A plan was adopted which required review of clinical pathway focusing on risk assessment, staff induction and a review of homeless services and interagency working. Despite the intervening eighteen months, progress on these was not evident and it was clear that these actions had not been completed. ”

Is this part of a recurring concern?

Yes — Failure to implement identified safety actions.

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 clarity of responsibility for risk assessment

Wider context from the report

“(2) After discharge in May, he was not followed up, as there was no address and his mobile phone number was not recorded. After attendance in June, again there was a failure to contact him for follow up, reported to be due to a phone failure. The failure to ensure reliable communication pathways for follow up is a potential risk for vulnerable patients. (3) The Serious Untoward Incident Report (Acute Mental Health Comprehensive Level Two Report, 10th October 2012) found seven areas of concern and service delivery problems, including weaknesses in risk assessment and recognition of suicide plan, lack of clarity of responsibility for risk assessment, inadequate 7 day follow up and communications with GP and problems in support as no mental illness. A plan was adopted which required review of clinical pathway focusing on risk assessment, staff induction and a review of homeless services and interagency working. Despite the intervening eighteen months, progress on these was not evident and it was clear that these actions had not been completed. ”

Is this part of a recurring concern?

Yes — Unclear accountability for safety risk assessments.

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 ensure reliable communication pathways for follow-up

Wider context from the report

“(2) After discharge in May, he was not followed up, as there was no address and his mobile phone number was not recorded. After attendance in June, again there was a failure to contact him for follow up, reported to be due to a phone failure. The failure to ensure reliable communication pathways for follow up is a potential risk for vulnerable patients. (3) The Serious Untoward Incident Report (Acute Mental Health Comprehensive Level Two Report, 10th October 2012) found seven areas of concern and service delivery problems, including weaknesses in risk assessment and recognition of suicide plan, lack of clarity of responsibility for risk assessment, inadequate 7 day follow up and communications with GP and problems in support as no mental illness. A plan was adopted which required review of clinical pathway focusing on risk assessment, staff induction and a review of homeless services and interagency working. Despite the intervening eighteen months, progress on these was not evident and it was clear that these actions had not been completed. ”

Is this part of a recurring concern?

Yes — Failure to maintain contact with vulnerable people after initial engagement; Failure to maintain follow-up of patients who disengage from care; Unreliable arrangement and communication of patient appointments and follow-up.

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 communicate patient risk and vulnerability to relevant agencies

Wider context from the report

“(1) Psychiatric staff did not properly assess his risk of self harm, nor communicate his vulnerability to others. At discharge on 10/05 his risk of self harm was not fully measured. On being seen on 14/06 his risk assessment was not recorded and the risk plan not sent to the GP. The consultant explained that the risk was not mitigatable as no mental illness was found. Evidence was heard that his forensic history indicated that he belonged to a group of patients with 80 times the risk of suicide compared with the general population, yet he was considered at low risk. The value of performing a proper risk assessment to demonstrate the risks and vulnerabilities of the patient to other agencies, such as housing and social services, does not seem to have been considered, although it was reluctantly conceded by the consultant to be of value especially as homelessness presented as the primary problem. ”

Is this part of a recurring concern?

Yes — Unreliable inter-agency information sharing for coordinated care; Unreliable multi-agency communication procedures.

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 properly assess and record self-harm and suicide risk

Wider context from the report

“(1) Psychiatric staff did not properly assess his risk of self harm, nor communicate his vulnerability to others. At discharge on 10/05 his risk of self harm was not fully measured. On being seen on 14/06 his risk assessment was not recorded and the risk plan not sent to the GP. The consultant explained that the risk was not mitigatable as no mental illness was found. Evidence was heard that his forensic history indicated that he belonged to a group of patients with 80 times the risk of suicide compared with the general population, yet he was considered at low risk. The value of performing a proper risk assessment to demonstrate the risks and vulnerabilities of the patient to other agencies, such as housing and social services, does not seem to have been considered, although it was reluctantly conceded by the consultant to be of value especially as homelessness presented as the primary problem. ”

Is this part of a recurring concern?

Yes — Inadequate mental health risk assessment; Unreliable assessment of suicide and self-harm risk; Unreliable recording of suicide-risk information.

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

Inadequate support for patients when no mental illness is identified

Wider context from the report

“(2) After discharge in May, he was not followed up, as there was no address and his mobile phone number was not recorded. After attendance in June, again there was a failure to contact him for follow up, reported to be due to a phone failure. The failure to ensure reliable communication pathways for follow up is a potential risk for vulnerable patients. (3) The Serious Untoward Incident Report (Acute Mental Health Comprehensive Level Two Report, 10th October 2012) found seven areas of concern and service delivery problems, including weaknesses in risk assessment and recognition of suicide plan, lack of clarity of responsibility for risk assessment, inadequate 7 day follow up and communications with GP and problems in support as no mental illness. A plan was adopted which required review of clinical pathway focusing on risk assessment, staff induction and a review of homeless services and interagency working. Despite the intervening eighteen months, progress on these was not evident and it was clear that these actions had not been completed. ”

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

Remind staff to record risk assessments in the correct electronic patient-record section.

Verbatim wording from the response

“The Trust’s policy on risk assessment is clear in its documentation and staff have been reminded to ensure that when risk is assessed, that this is documented in the correct fashion in the relevant section of the electronic patient record to ensure that this is easily accessible by all clinical staff.”

Source location

2014-0212-Response-by-South-London-Maudsley-NHS-Trust
Page 2 · response
Published 9 May 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

Secure £250,000 funding to pilot a mental-health-specific homeless project linked to an established homeless support scheme.

Verbatim wording from the response

“Homelessness features highly amongst the patients that the Trust cares for. However, I am pleased to inform you that we have been successful in obtaining funding in the sum of £250,000 from the Guys and St Thomas’ Hospital Charity to pilot a mental health specific homeless project working with those who present to our services. This will be linked to an existing scheme which is in place across King’s and St Thomas’ Hospitals for those who enter our services who are homeless, and where our staff will have direct access to the expertise in an already established homeless scheme. I am sure that this will lead to an improvement in the service we can provide to patients who are in this unfortunate situation.”

Source location

2014-0212-Response-by-South-London-Maudsley-NHS-Trust
Page 4 · response
Published 9 May 2014

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 was attempted using the patient’s recorded telephone number and messages through A&E, rather than wholly failing through absent communication pathways.

Verbatim wording from the response

“A further review of Mr Richards’ records indicates that when he was seen in the outpatient clinic in June, the service was aware of his mobile phone number. In fact, he had been called the day before by a social worker at the community team and asked to attend the outpatient appointment on 14 June as his GP had been concerned that he had again reported suicidal ideation.”

Source location

2014-0212-Response-by-South-London-Maudsley-NHS-Trust
Page 2 · response
Published 9 May 2014

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

Referring the homeless patient to SHIP was considered the correct and only available way to mitigate his suicide risk.

Verbatim wording from the response

“I believe that the clinicians involved in Mr Richards’ care were aware of the impact of his homelessness on his risk of suicide and that their focus on ensuring that he received the help that he required, by referring him to the Single Homeless Intervention and Prevention agency (SHIP) was the correct course of action to follow. This was, in reality, all that they could do to mitigate the suicide risk.”

Source location

2014-0212-Response-by-South-London-Maudsley-NHS-Trust
Page 2 · response
Published 9 May 2014

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

Risk was assessed during admission but recorded in the wrong electronic-record location, rather than not being assessed.

Verbatim wording from the response

“It is correct that there is no formal documentation of risk in the correct location on the PJS (our electronic patient record system) either at the point of his presentation under Section 136 or whilst on the Triage Ward. This was noted in the Trust’s investigators in their report. However, there is clear evidence in the clinical records that risk was assessed and is documented in the detailed entries made by the ward medical staff during his admission. It was acknowledged that there was a risk of suicide but this was not linked to mental illness but rather the difficult circumstances he found himself in, in particular, his homelessness.”

Source location

2014-0212-Response-by-South-London-Maudsley-NHS-Trust
Page 2 · response
Published 9 May 2014

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

Further contact was constrained because the patient remained homeless and his sole recorded telephone number became unobtainable.

Verbatim wording from the response

“She tried, using the number on file, but it was unobtainable. There was no other way of making contact with Mr Richards, so she left a message at the A&E department asking him to make contact with her should he re-present as he had booked an appointment to see her on 2 October.”

Source location

2014-0212-Response-by-South-London-Maudsley-NHS-Trust
Page 3 · response
Published 9 May 2014

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

The method of threatened suicide was considered insignificant to this case because staff addressed the risk through accommodation support.

Verbatim wording from the response

“Although Mr Richards did not have a mental illness, staff did acknowledge his suicidal intent and were aware that this was directly related to his homelessness. It is clear from his records that there was recurrent mention of committing suicide by jumping in front of a train. Although this may not have been noted specifically by the clinical team, his recurrent mention of suicide was. I do not feel that the method by which he said he would commit suicide is significant in this particular case. The way of addressing this was through assisting him in finding accommodation through SHIP. In order to obtain help through SHIP, he needed to be officially homeless and could not be considered as such, as long as his name was on the tenancy of the property he had shared with his wife.”

Source location

2014-0212-Response-by-South-London-Maudsley-NHS-Trust
Page 4 · response
Published 9 May 2014

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 positions A position is what a recipient says about a concern when they do not describe a specific action.1

  1. 1

    The claimed eightyfold suicide-risk statistic was unsupported and considered irrelevant because the patient had no mental illness.

    Stated by South London and Maudsley NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

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 claimed eightyfold suicide-risk statistic was unsupported and considered irrelevant because the patient had no mental illness.

Verbatim wording from the response

“I am not aware specifically of any research evidence that suggests that those with a forensic background have a suicide risk 80 times higher than the general population but I do acknowledge that the risk is greater in those who have a mental illness and a forensic background. I do not feel that this is relevant in Mr Richards’ case as he did not have a mental illness.”

Source location

2014-0212-Response-by-South-London-Maudsley-NHS-Trust
Page 2 · response
Published 9 May 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