PFD report

Carl Robert ELLSON · Prevention of Future Deaths report

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Issued 20 Dec 2022•Birmingham and Solihull

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
2

Named on the report

Responses found
2

Of 2 recipients

Stated actions
6

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. Lack of a clear and safe system for GPs to contact mental health teams for urgent reviews
    Part of recurring concern: Unreliable community mental-health response to urgent GP concerns
  2. Failure to arrange mental health practitioner contact without placing the burden on patients in crisis
    Part of recurring concern: Unreliable urgent mental health referral and assessment pathways
  3. Lack of GP awareness of how to request urgent psychiatric reviews
    Part of recurring concern: Unclear and unreliable GP access and referral pathwaysPart of recurring concern: Unreliable urgent mental health referral and assessment pathways
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.4

  1. Action

    Refresh Teamnet referral information to ensure it is relevant and prominent.

    Stated by Herefordshire and Worcestershire Health and Care NHS Trust and NHS Herefordshire and Worcestershire Integrated Care BoardStated in progressThe respondent said that this action was in progress when they made their response on 20 December 2022.
  2. Action

    Disseminate information to GPs about urgent psychiatric review routes through direct communications, Teamnet and primary care network meetings.

    Stated by Herefordshire and Worcestershire Health and Care NHS Trust and NHS Herefordshire and Worcestershire Integrated Care BoardStated in progressThe respondent said that this action was in progress when they made their response on 20 December 2022.
  3. Action

    Continue issuing all GP surgeries reminders of mental health referral contact numbers through Teamnet.

    Stated by Herefordshire and Worcestershire Health and Care NHS Trust and NHS Herefordshire and Worcestershire Integrated Care BoardStated in progressThe respondent said that this action was in progress when they made their response on 20 December 2022.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.3

  1. Position

    The established urgent-access process, including Single Point of Access, Home Treatment, Crisis Team and out-of-hours arrangements, is considered sufficient.

    Stated by Herefordshire and Worcestershire Health and Care NHS Trust and NHS Herefordshire and Worcestershire Integrated Care BoardExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.

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 a clear and safe system for GPs to contact mental health teams for urgent reviews

Wider context from the report

“1. On 13/07/22 Dr Ellson's GP needed to arrange an urgent mental health review as Dr Ellson had presented with suicidal ideation. The GP had significant difficulties trying to contact the Mental health team with messages giving incorrect numbers. My concern is that the system for GPs to contact mental health teams for urgent reviews is not clear nor safe. ”

Is this part of a recurring concern?

Yes — Unreliable community mental-health response to urgent GP concerns.

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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 arrange mental health practitioner contact without placing the burden on patients in crisis

Wider context from the report

“2. Once contact had been made and a request was made for Dr Ellson to be assessed by the mental health team, the system in place is for the patient to call the mental health practitioner. My concern is that the patient is likely to be in crisis, which is why a referral is being made, and the burden should not be put on them to make the call. ”

Is this part of a recurring concern?

Yes — Unreliable urgent mental health referral and assessment pathways.

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 GP awareness of how to request urgent psychiatric reviews

Wider context from the report

“3. The GP caring for Dr Ellson on 13/07/22 was unaware that she could make a request for a psychiatric review of the patient. The inquest heard how this was not well known by local GPs. My concern is that GPs should be fully aware how to request an urgent psychiatric review for patients. ”

Is this part of a recurring concern?

Yes — Unclear and unreliable GP access and referral pathways; Unreliable urgent mental health referral and assessment pathways.

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

Refresh Teamnet referral information to ensure it is relevant and prominent.

Verbatim wording from the response

“same numbers available to the public. Both email address and contact telephone number are prominent on the GP Referral Form. Whilst we believe GPs are aware of the correct numbers, going forward, we will continue to issue reminders to all GP surgeries of the contact numbers through Teamnet, which is the service used for all referral and service information. Between our two organisations we are refreshing all of the information on Teamnet, to ensure that the information is both relevant and prominent.”

Source location

Response from NHS Herefordshire and Worcestershire
Page 2 · response
Published 20 December 2022

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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

Disseminate information to GPs about urgent psychiatric review routes through direct communications, Teamnet and primary care network meetings.

Verbatim wording from the response

“The Trust’s investigation did identify that the GP in this case would have liked to refer directly to a psychiatrist. We understood that they were reassured that the Trust follows the national model. Within our process the patient can see a consultant psychiatrist if they were taken on by the Home Treatment Team, as medical reviews are an integral part of how that team operates. The action from the investigation was therefore to ensure that local GPs were supported and provided with this information going forward. Again, this was achieved by sending all GPs direct communications with a reminder of this information on 31st December 2022. In addition, we have ensured that the relevant information is on Teamnet and also regularly discussed in the local primary care network meetings between GPs and their local mental health teams.”

Source location

Response from NHS Herefordshire and Worcestershire
Page 3 · response
Published 20 December 2022

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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

Continue issuing all GP surgeries reminders of mental health referral contact numbers through Teamnet.

Verbatim wording from the response

“same numbers available to the public. Both email address and contact telephone number are prominent on the GP Referral Form. Whilst we believe GPs are aware of the correct numbers, going forward, we will continue to issue reminders to all GP surgeries of the contact numbers through Teamnet, which is the service used for all referral and service information. Between our two organisations we are refreshing all of the information on Teamnet, to ensure that the information is both relevant and prominent.”

Source location

Response from NHS Herefordshire and Worcestershire
Page 2 · response
Published 20 December 2022

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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

Use the Medical Leadership Forum to reiterate the urgent referral process and address concerns.

Verbatim wording from the response

“As part of striving for continuous improvement our Medical Leadership Forum (which includes the ICB, Trust and General Practice) will also take this issue forward, to reiterate the process and ensure any concerns are addressed.”

Source location

Response from NHS Herefordshire and Worcestershire
Page 2 · response
Published 20 December 2022

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 established urgent-access process, including Single Point of Access, Home Treatment, Crisis Team and out-of-hours arrangements, is considered sufficient.

Verbatim wording from the response

“The Trust’s current process for enabling urgent access to mental health services is longstanding and we thought well recognised. GPs can contact the Single Point of Access (SPA) who pass the referral on to the relevant/local Home Treatment Team (HTT) who then triage the referral and either allocate themselves or the Crisis Team dependent on risk and clinical presentation. If a call comes through out of hours, it goes straight to the Crisis team which is a 24/7 service.”

Source location

Response from NHS Herefordshire and Worcestershire
Page 1 · response
Published 20 December 2022

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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

Patients in crisis are not expected to initiate contact; Home Treatment or Crisis Teams contact patients after referral and triage.

Verbatim wording from the response

“We would like to reassure you that a process is in place which does not burden the patient with the responsibility of making a call to initiate engagement with services when in a crisis. In this instance, the patient in this case was not asked by the Home Treatment Team or the Crisis Team to call them at any point. Further, it is never the usual process for a patient to contact Home Treatment following a referral from a GP. The call takers from both the Home Treatment Team and the Crisis Team, who took the call from the SPA on the day in question both state they did not ask the GP to tell the patient to call either team. This is supported by the contemporaneous recording following the conversations.”

Source location

Response from NHS Herefordshire and Worcestershire
Page 2 · response
Published 20 December 2022

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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

Home Treatment or Crisis clinicians, rather than GPs, determine and arrange urgent psychiatric medical review following assessment.

Verbatim wording from the response

“The Trust follows a national model which allows GPs to refer for an urgent psychiatric assessment in terms of a psycho-social assessment by a Home Treatment or Crisis Clinician, and within that they can provide an opinion that they believe a medical review from a psychiatrist is required. However, the gatekeeping for this, as well as the responsibility to arrange it, falls on the Home Treatment and/or Crisis Clinician completing the subsequent assessment. GPs can also refer to the Neighbourhood Mental Health Team for a review from a psychiatrist although this route is not intended for urgent referrals.”

Source location

Response from NHS Herefordshire and Worcestershire
Page 3 · response
Published 20 December 2022

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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

    Review the crisis pathway to identify further improvements.

    Stated by Herefordshire and Worcestershire Health and Care NHS Trust and NHS Herefordshire and Worcestershire Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 20 December 2022.
  2. 2

    Commission third-party work to better understand patient experience in mental health services.

    Stated by Herefordshire and Worcestershire Health and Care NHS Trust and NHS Herefordshire and Worcestershire Integrated Care BoardStated completedThe respondent said that this action was complete when they made their response on 20 December 2022.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.2

  1. 1

    The national-model crisis system is considered appropriate because urgent medical input is available when gatekeeping teams identify a need.

    Stated by Herefordshire and Worcestershire Health and Care NHS Trust and NHS Herefordshire and Worcestershire Integrated Care BoardExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
  2. 2

    A consultant psychiatrist review was considered clinically unnecessary in this case, and the assessment outcome was considered appropriate.

    Stated by Herefordshire and Worcestershire Health and Care NHS Trust and NHS Herefordshire and Worcestershire Integrated Care BoardDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

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 the crisis pathway to identify further improvements.

Verbatim wording from the response

“Both the Trust and ICB are working closely with primary care to ensure that our services are fit for purpose and have mechanisms in place to discuss any concerns that arise. The issues that have been raised will be discussed through these local fora on an anonymised basis, to capture any additional actions. As part of our operational delivery of mental health services, work has been commissioned from a third party to better understand the patient experience, one of our priority areas will be to review the crisis pathway to identify any further improvements.”

Source location

Response from NHS Herefordshire and Worcestershire
Page 3 · response
Published 20 December 2022

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

Commission third-party work to better understand patient experience in mental health services.

Verbatim wording from the response

“Both the Trust and ICB are working closely with primary care to ensure that our services are fit for purpose and have mechanisms in place to discuss any concerns that arise. The issues that have been raised will be discussed through these local fora on an anonymised basis, to capture any additional actions. As part of our operational delivery of mental health services, work has been commissioned from a third party to better understand the patient experience, one of our priority areas will be to review the crisis pathway to identify any further improvements.”

Source location

Response from NHS Herefordshire and Worcestershire
Page 3 · response
Published 20 December 2022

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 national-model crisis system is considered appropriate because urgent medical input is available when gatekeeping teams identify a need.

Verbatim wording from the response

“Whilst we appreciate your concerns our clinical view is that the current system, which follows the national model, is appropriate. If following an urgent assessment/review by one of our gatekeeping teams (Crisis Resolution or Home Treatment) there is an identified need for urgent medical input, we have access to psychiatrists in hours or on-call psychiatrists out of hours. However, in this case, our view was that a review by a consultant psychiatrist was not clinically indicated and following the internal investigation we were satisfied that the outcome of the assessment was appropriate.”

Source location

Response from NHS Herefordshire and Worcestershire
Page 3 · response
Published 20 December 2022

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

A consultant psychiatrist review was considered clinically unnecessary in this case, and the assessment outcome was considered appropriate.

Verbatim wording from the response

“Whilst we appreciate your concerns our clinical view is that the current system, which follows the national model, is appropriate. If following an urgent assessment/review by one of our gatekeeping teams (Crisis Resolution or Home Treatment) there is an identified need for urgent medical input, we have access to psychiatrists in hours or on-call psychiatrists out of hours. However, in this case, our view was that a review by a consultant psychiatrist was not clinically indicated and following the internal investigation we were satisfied that the outcome of the assessment was appropriate.”

Source location

Response from NHS Herefordshire and Worcestershire
Page 3 · response
Published 20 December 2022

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