PFD report

Katy Roberts · Prevention of Future Deaths report

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Issued 27 Apr 2018•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
3

Raised in this report

Recipients
3

Named on the report

Responses found
1

Of 3 recipients

Stated actions
9

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 expressly communicate in writing all routes for raising concerns and seeking help
  2. Failure to provide a clear route or opportunity to challenge or appeal Care Plan changes
    Part of recurring concern: Unreliable appeal and challenge routes for care decisions
  3. Failure to communicate in writing a Care Plan and changes to it
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.7

  1. Action

    Remind staff to routinely provide written guidance explaining how young people and families can seek emergency and non-emergency help.

    Stated by South London and Maudsley NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 1 July 2018.
  2. Action

    Develop an implementation plan to introduce the Community Care Plan across CAMHS community teams.

    Stated by South London and Maudsley NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 1 July 2018.
  3. Action

    Ensure young people and families review proposed Community Care Plans and agree or change them within four working weeks.

    Stated by South London and Maudsley NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 1 July 2018.

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 expressly communicate in writing all routes for raising concerns and seeking help

Wider context from the report

“(3) Failure to expressly communicate in writing all routes by which, to raise concerns and seek help on a non-emergency or emergency basis. ”

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 provide a clear route or opportunity to challenge or appeal Care Plan changes

Wider context from the report

“(2) Failure to provide a clear route or opportunity to challenge or appeal these changes to the Care Plan. ”

Is this part of a recurring concern?

Yes — Unreliable appeal and challenge routes for care decisions.

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 in writing a Care Plan and changes to it

Wider context from the report

“(1) Failure to communicate in writing a Care Plan and changes to it. ”

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 routinely provide written guidance explaining how young people and families can seek emergency and non-emergency help.

Verbatim wording from the response

“3. Guidance to Young People, their Parents and Carers All CAMHS community services provide clear written guidance to Young People, their families and other agencies on how to seek help from CAMHS and other services. We will remind all staff to make this information available routinely and will conduct a survey with service user, carers and parents in January 2019 to assure the CAMHS Directorate operational management teams that the information is being made available.”

Source location

2018-0136-Response-by-South-London-and-Maudsley
Page 2 · response
Published 1 July 2018

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 an implementation plan to introduce the Community Care Plan across CAMHS community teams.

Verbatim wording from the response

“1. Written Care Plan All CAMHS community practitioners, working with Young People with complex mental health difficulties, will complete a Community Care Plan with the Young Person concerned. While this has been our practice for some time, we have not adopted a consistent way of writing and sharing care plans and risk assessments. The Trust completed the testing of the Community Care Plan in June 2018 and CAMHS is now developing an implementation plan for its introduction across community teams. A Community Care Plan summary document is attached with this response.”

Source location

2018-0136-Response-by-South-London-and-Maudsley
Page 1 · response
Published 1 July 2018

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

Ensure young people and families review proposed Community Care Plans and agree or change them within four working weeks.

Verbatim wording from the response

“CAMHS community practitioners will ensure that the Community Care Plan proposed is reviewed by the Young Person and their family and then either agreed, or changed, within 4 working weeks. The number of Community Care Plans changed, following challenge or appeal will be audited and performance considered by CAMHS Directorate Operational Governance meeting each Quarter.”

Source location

2018-0136-Response-by-South-London-and-Maudsley
Page 2 · response
Published 1 July 2018

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

Monitor Community Care Plan implementation and communication through patient-led reports, supervision, monthly performance meetings and quarterly governance reviews.

Verbatim wording from the response

“Monitoring of implementation and communication of the plans, at individual practitioner and team leader level, will be enabled by patient led reports and supervision. CAMHS Borough Community Services will include this new”

Source location

2018-0136-Response-by-South-London-and-Maudsley
Page 1 · response
Published 1 July 2018

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 the Southwark Emergency and Developing Crisis Protocol with GPs, school counsellors, young people and their families.

Verbatim wording from the response

“Southwark now has an Emergency and Developing Crisis Protocol, which has been widely shared with GPs, schools counsellors, Young People and their families; a copy is attached.”

Source location

2018-0136-Response-by-South-London-and-Maudsley
Page 2 · response
Published 1 July 2018

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

Survey service users, carers and parents in January 2019 to assess whether help-seeking information is being made available.

Verbatim wording from the response

“3. Guidance to Young People, their Parents and Carers All CAMHS community services provide clear written guidance to Young People, their families and other agencies on how to seek help from CAMHS and other services. We will remind all staff to make this information available routinely and will conduct a survey with service user, carers and parents in January 2019 to assure the CAMHS Directorate operational management teams that the information is being made available.”

Source location

2018-0136-Response-by-South-London-and-Maudsley
Page 2 · response
Published 1 July 2018

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

Audit Community Care Plans changed after challenge or appeal and consider performance quarterly through CAMHS Directorate Operational Governance.

Verbatim wording from the response

“CAMHS community practitioners will ensure that the Community Care Plan proposed is reviewed by the Young Person and their family and then either agreed, or changed, within 4 working weeks. The number of Community Care Plans changed, following challenge or appeal will be audited and performance considered by CAMHS Directorate Operational Governance meeting each Quarter.”

Source location

2018-0136-Response-by-South-London-and-Maudsley
Page 2 · response
Published 1 July 2018

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.2

  1. 1

    Complete testing of the Community Care Plan for CAMHS community teams.

    Stated by South London and Maudsley NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 1 July 2018.
  2. 2

    Require CAMHS community practitioners working with young people with complex mental health difficulties to complete a Community Care Plan with each young person.

    Stated by South London and Maudsley NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 1 July 2018.

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

Complete testing of the Community Care Plan for CAMHS community teams.

Verbatim wording from the response

“1. Written Care Plan All CAMHS community practitioners, working with Young People with complex mental health difficulties, will complete a Community Care Plan with the Young Person concerned. While this has been our practice for some time, we have not adopted a consistent way of writing and sharing care plans and risk assessments. The Trust completed the testing of the Community Care Plan in June 2018 and CAMHS is now developing an implementation plan for its introduction across community teams. A Community Care Plan summary document is attached with this response.”

Source location

2018-0136-Response-by-South-London-and-Maudsley
Page 1 · response
Published 1 July 2018

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

Require CAMHS community practitioners working with young people with complex mental health difficulties to complete a Community Care Plan with each young person.

Verbatim wording from the response

“1. Written Care Plan All CAMHS community practitioners, working with Young People with complex mental health difficulties, will complete a Community Care Plan with the Young Person concerned. While this has been our practice for some time, we have not adopted a consistent way of writing and sharing care plans and risk assessments. The Trust completed the testing of the Community Care Plan in June 2018 and CAMHS is now developing an implementation plan for its introduction across community teams. A Community Care Plan summary document is attached with this response.”

Source location

2018-0136-Response-by-South-London-and-Maudsley
Page 1 · response
Published 1 July 2018

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