PFD report

Lucy Amanda Jones · Prevention of Future Deaths report

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Issued 11 Jan 2023•Gwent

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
3

Raised in this report

Recipients
1

Named on the report

Responses found
2

Of 1 recipient

Stated actions
4

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. Delays in access to Cognitive Behavioural Therapy
    Part of recurring concern: Excessive waiting times for NHS mental health servicesPart of recurring concern: Failure to provide indicated psychological interventions in mental health care
  2. Failure to make adequate efforts to establish contact when a patient cannot be reached
    Part of recurring concern: Unreliable patient contact during urgent recall and follow-up
  3. Failure to provide planned community follow-up within the required timeframe
    Part of recurring concern: Failure to provide timely continuing mental health reviews 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

    Finalize, consult on and submit the Disengagement and Did Not Attend policy for ratification.

    Stated by Aneurin Bevan University LHBStated in progressThe respondent said that this action was in progress when they made their response on 16 January 2023.
  2. Action

    Pilot embedded psychological care with outpatient follow-up and smoother transition pathways.

    Stated by Aneurin Bevan University LHBStated in progressThe respondent said that this action was in progress when they made their response on 16 January 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

Delays in access to Cognitive Behavioural Therapy

Wider context from the report

“1. Lucy Amanda Jones was admitted to Talygarn Ward at The County Hospital Pontypool in December 2019 under Section 2 of the Mental Health Act. On discharge from hospital, she was placed on the waiting list for Cognitive Behavioural Therapy (CBT). In evidence provided by her General Practitioner, I was informed that Lucy was still waiting for CBT at the time of her death in March 2022. 2. Following Lucy’s death a concise review of the care she had received from the mental health team was undertaken. The review noted that following a consultant review in January 2022, Lucy was due to be followed up in the community within 2 weeks, but that in fact she was not seen again prior to her death. The Community Psychiatric Nurse (CPN) attempted to make contact by phone only 2 occasions and did not speak to Lucy. The CPN was apparently reassured by Lucy’s housemate, who had no concerns for Lucy. No efforts were made to “cold call” when Lucy could not be contacted. ”

Is this part of a recurring concern?

Yes — Excessive waiting times for NHS mental health services; Failure to provide indicated psychological interventions in mental health care.

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 adequate efforts to establish contact when a patient cannot be reached

Wider context from the report

“1. Lucy Amanda Jones was admitted to Talygarn Ward at The County Hospital Pontypool in December 2019 under Section 2 of the Mental Health Act. On discharge from hospital, she was placed on the waiting list for Cognitive Behavioural Therapy (CBT). In evidence provided by her General Practitioner, I was informed that Lucy was still waiting for CBT at the time of her death in March 2022. 2. Following Lucy’s death a concise review of the care she had received from the mental health team was undertaken. The review noted that following a consultant review in January 2022, Lucy was due to be followed up in the community within 2 weeks, but that in fact she was not seen again prior to her death. The Community Psychiatric Nurse (CPN) attempted to make contact by phone only 2 occasions and did not speak to Lucy. The CPN was apparently reassured by Lucy’s housemate, who had no concerns for Lucy. No efforts were made to “cold call” when Lucy could not be contacted. ”

Is this part of a recurring concern?

Yes — Unreliable patient contact during urgent recall 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 provide planned community follow-up within the required timeframe

Wider context from the report

“1. Lucy Amanda Jones was admitted to Talygarn Ward at The County Hospital Pontypool in December 2019 under Section 2 of the Mental Health Act. On discharge from hospital, she was placed on the waiting list for Cognitive Behavioural Therapy (CBT). In evidence provided by her General Practitioner, I was informed that Lucy was still waiting for CBT at the time of her death in March 2022. 2. Following Lucy’s death a concise review of the care she had received from the mental health team was undertaken. The review noted that following a consultant review in January 2022, Lucy was due to be followed up in the community within 2 weeks, but that in fact she was not seen again prior to her death. The Community Psychiatric Nurse (CPN) attempted to make contact by phone only 2 occasions and did not speak to Lucy. The CPN was apparently reassured by Lucy’s housemate, who had no concerns for Lucy. No efforts were made to “cold call” when Lucy could not be contacted. ”

Is this part of a recurring concern?

Yes — Failure to provide timely continuing mental health reviews and follow-up.

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

Finalize, consult on and submit the Disengagement and Did Not Attend policy for ratification.

Verbatim wording from the response

“With regard to the policy that determines what steps should be taken to ensure that mental health practitioners can be properly reassured about the health of their patients who are refusing or reluctant to engage, the Adult Mental Health and Specialist Services Directorate has developed a policy to guide clinicians in their next steps when a person does not attend”

Source location

Response from Aneurin Bevan University Health Board
Page 2 · response
Published 16 January 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

Pilot embedded psychological care with outpatient follow-up and smoother transition pathways.

Verbatim wording from the response

“In regard to this particular case, since this time the Health Board has invested further in psychological input to acute treatment areas and is piloting a model of embedded psychological care which gives some provision for outpatient follow-up. This allows for smoother transitions, increased relational consistency (rather than needing to develop a new therapeutic relationship with a different clinician), and more effective care pathways. There is, of course, also the growth in the ‘Open Dialogue’ model of care (a model of mental health care which involves a consistent family and social network approach where all treatment is carried out via a whole system/network meeting, which always include the patient) and this is being provided by multi-disciplinary staff embedded in both acute care environments and community provision.”

Source location

Response from Aneurin Bevan University Health Board
Page 2 · response
Published 16 January 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.2

  1. 1

    Provide Open Dialogue care through multidisciplinary staff embedded across acute and community services.

    Stated by Aneurin Bevan University LHBStated completedThe respondent said that this action was complete when they made their response on 16 January 2023.
  2. 2

    Invest further in psychological input for acute treatment areas.

    Stated by Aneurin Bevan University LHBStated completedThe respondent said that this action was complete when they made their response on 16 January 2023.

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

  1. 1

    Clinicians cannot compel treatment when a person with capacity refuses or declines intervention and no statutory power applies.

    Stated by Aneurin Bevan University LHBUnable to actThe respondent said that a constraint prevented them from taking the relevant action.

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

Provide Open Dialogue care through multidisciplinary staff embedded across acute and community services.

Verbatim wording from the response

“In regard to this particular case, since this time the Health Board has invested further in psychological input to acute treatment areas and is piloting a model of embedded psychological care which gives some provision for outpatient follow-up. This allows for smoother transitions, increased relational consistency (rather than needing to develop a new therapeutic relationship with a different clinician), and more effective care pathways. There is, of course, also the growth in the ‘Open Dialogue’ model of care (a model of mental health care which involves a consistent family and social network approach where all treatment is carried out via a whole system/network meeting, which always include the patient) and this is being provided by multi-disciplinary staff embedded in both acute care environments and community provision.”

Source location

Response from Aneurin Bevan University Health Board
Page 2 · response
Published 16 January 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

Invest further in psychological input for acute treatment areas.

Verbatim wording from the response

“In regard to this particular case, since this time the Health Board has invested further in psychological input to acute treatment areas and is piloting a model of embedded psychological care which gives some provision for outpatient follow-up. This allows for smoother transitions, increased relational consistency (rather than needing to develop a new therapeutic relationship with a different clinician), and more effective care pathways. There is, of course, also the growth in the ‘Open Dialogue’ model of care (a model of mental health care which involves a consistent family and social network approach where all treatment is carried out via a whole system/network meeting, which always include the patient) and this is being provided by multi-disciplinary staff embedded in both acute care environments and community provision.”

Source location

Response from Aneurin Bevan University Health Board
Page 2 · response
Published 16 January 2023

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

Clinicians cannot compel treatment when a person with capacity refuses or declines intervention and no statutory power applies.

Verbatim wording from the response

“The policy seeks to explore and balance the clinician and team’s duty of care to that patient along with the person’s right to refuse/decline treatment and intervention - where the person has the mental capacity to make this decision and there is no statutory power to compel this. The policy supports clinical decision making based on the person’s needs, identified/known risks and any information from others. It supports communication required with the patient and others (where indicated) and the views of the multi-disciplinary team, and advice for the patient i.e., routes back to the mental health service should their mental health deteriorate.”

Source location

Response from Aneurin Bevan University Health Board
Page 3 · response
Published 16 January 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