Joshua Lewis BROWN · Prevention of Future Deaths report

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Issued 17 Jul 2014•North East Kent

Published report and response evidence

This report’s concerns and statements found in recipients’ published responses. Statements are included even where no link to an individual concern is recorded. A link shows an evidence connection; it does not assign responsibility.

View original report
Concerns
3

Raised in this report

Recipients
3

Named on the report

Responses found
1

Of 3 recipients

Stated actions
2

Described in responses

Recipients and published responses

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 inform family members about available support information and support for themselves
    Part of recurring concern: Failure to provide families with information needed to support people receiving mental health care
  2. Failure to engage family members in support when information sharing is declined
  3. Failure to verify the accuracy and interpretation of information recorded from family members

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. Department of Health and Social Care

    Facilitate and publish a confidentiality, information-sharing and suicide-prevention consensus statement alongside the first annual suicide-prevention strategy report.

  2. Department of Health and Social Care

    Discuss the confidentiality consensus statement at the next National Suicide Prevention Strategy Advisory Group meeting.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.1

  1. Department of Health and Social Care

    Clinicians cannot disclose confidential information when a capable patient at suicide risk refuses consent and disclosure is not otherwise warranted.

    Unable to actThe respondent said that a constraint prevented them from taking the relevant action.

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 inform family members about available support information and support for themselves

Wider context from the report

“(1) The evidence was that Mr Brown lived with his parents who were therefore his primary support outside the Community Health Team but were not strictly speaking his carers and therefore were not formally able to be involved as such by the Community Team when Mr Brown did not wish information about him to be shared. They therefore did not receive information that might have alerted them to periods when he was particularly vulnerable and when they might have had information that would have been of assistance to the Team in caring for Mr Brown. (2) The evidence also demonstrated that it was not the practice of the Team to show family members what notes had been made by the Team of information shared with them by family members, with the consequence that inaccuracies or misunderstandings may have arisen in some notes, and there was no provision for those notes to be signed as accurate by the relevant family members. (3) The family members were not made aware of ways in which they could obtain through the Kent and Medway NHS Social Care and Partnership Trust (of which the Team was a part) more information about how they might best support Mr Brown and themselves receive support. (4) In general, the evidence showed limitations on the possibilities for engagement by the Team with family members and by family members with the Team, particularly when Mr Brown did not wish information about him to be shared and this worked to his disadvantage. There was, however, evidence of some improvement having already been made by the Trust in this respect. When engagement was possible, the absence of a system whereby a person giving information to the Team would check that that information had been correctly noted and interpreted by the Team posed obvious risks for anyone under the care of the Team. ”

Is this part of a recurring concern?

Yes — Failure to provide families with information needed to support people receiving 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 engage family members in support when information sharing is declined

Wider context from the report

“(1) The evidence was that Mr Brown lived with his parents who were therefore his primary support outside the Community Health Team but were not strictly speaking his carers and therefore were not formally able to be involved as such by the Community Team when Mr Brown did not wish information about him to be shared. They therefore did not receive information that might have alerted them to periods when he was particularly vulnerable and when they might have had information that would have been of assistance to the Team in caring for Mr Brown. (2) The evidence also demonstrated that it was not the practice of the Team to show family members what notes had been made by the Team of information shared with them by family members, with the consequence that inaccuracies or misunderstandings may have arisen in some notes, and there was no provision for those notes to be signed as accurate by the relevant family members. (3) The family members were not made aware of ways in which they could obtain through the Kent and Medway NHS Social Care and Partnership Trust (of which the Team was a part) more information about how they might best support Mr Brown and themselves receive support. (4) In general, the evidence showed limitations on the possibilities for engagement by the Team with family members and by family members with the Team, particularly when Mr Brown did not wish information about him to be shared and this worked to his disadvantage. There was, however, evidence of some improvement having already been made by the Trust in this respect. When engagement was possible, the absence of a system whereby a person giving information to the Team would check that that information had been correctly noted and interpreted by the Team posed obvious risks for anyone under the care of the Team. ”

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 verify the accuracy and interpretation of information recorded from family members

Wider context from the report

“(1) The evidence was that Mr Brown lived with his parents who were therefore his primary support outside the Community Health Team but were not strictly speaking his carers and therefore were not formally able to be involved as such by the Community Team when Mr Brown did not wish information about him to be shared. They therefore did not receive information that might have alerted them to periods when he was particularly vulnerable and when they might have had information that would have been of assistance to the Team in caring for Mr Brown. (2) The evidence also demonstrated that it was not the practice of the Team to show family members what notes had been made by the Team of information shared with them by family members, with the consequence that inaccuracies or misunderstandings may have arisen in some notes, and there was no provision for those notes to be signed as accurate by the relevant family members. (3) The family members were not made aware of ways in which they could obtain through the Kent and Medway NHS Social Care and Partnership Trust (of which the Team was a part) more information about how they might best support Mr Brown and themselves receive support. (4) In general, the evidence showed limitations on the possibilities for engagement by the Team with family members and by family members with the Team, particularly when Mr Brown did not wish information about him to be shared and this worked to his disadvantage. There was, however, evidence of some improvement having already been made by the Trust in this respect. When engagement was possible, the absence of a system whereby a person giving information to the Team would check that that information had been correctly noted and interpreted by the Team posed obvious risks for anyone under the care of the Team. ”

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

Facilitate and publish a confidentiality, information-sharing and suicide-prevention consensus statement alongside the first annual suicide-prevention strategy report.

Verbatim wording from the response

“The Department has therefore facilitated a consensus statement on confidentiality, Information sharing and suicide prevention: consensus statement, which was published in January 2014 alongside the first annual report on the suicide prevention strategy.”

Source location

2014-0289-Response-by-Department-of-Health
Page 2 · response
Published 17 July 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

Discuss the confidentiality consensus statement at the next National Suicide Prevention Strategy Advisory Group meeting.

Verbatim wording from the response

“This work was supported by our National Suicide Prevention Strategy Advisory Group. The consensus statement will be discussed again at the next meeting of this group in November 2014.”

Source location

2014-0289-Response-by-Department-of-Health
Page 3 · response
Published 17 July 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

Clinicians cannot disclose confidential information when a capable patient at suicide risk refuses consent and disclosure is not otherwise warranted.

Verbatim wording from the response

“Current legislation provides that, where a clinician believes that a patient is at risk of suicide, and that patient refuses to provide consent for information to be shared with family members or any other third party, and, in the judgement of the clinician, the patient has full mental capacity to understand the risks, then disclosure of that patient’s confidential information is not warranted.”

Source location

2014-0289-Response-by-Department-of-Health
Page 2 · response
Published 17 July 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