PFD report

Wendy Siobhan EYLES · Prevention of Future Deaths report

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Issued 22 Dec 2025•Northamptonshire

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
2

Named on the report

Responses found
1

Of 2 recipients

Stated actions
1

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 of notification pathways to ensure NHS mental health services are aware of private psychiatric treatment
    Part of recurring concern: Unreliable coordination and escalation between care providers and mental health servicesPart of recurring concern: Unreliable inter-agency information sharing for coordinated care
  2. Lack of a protocol for patients receiving concurrent private and NHS psychiatry
    Part of recurring concern: Failure to integrate mental health services across care settingsPart of recurring concern: Unreliable coordination and escalation between care providers and mental health services
  3. Failure to communicate medication changes between private and NHS psychiatric providers
    Part of recurring concern: Unreliable coordination and escalation between care providers and mental health servicesPart of recurring concern: Unreliable implementation of medication changesPart of recurring concern: Unreliable inter-specialty communication for complex patient carePart of recurring concern: Unsafe coordination of shared care
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.1

  1. Action

    Develop and complete a Trust-wide protocol for managing patients receiving simultaneous NHS and private psychiatric care.

    Stated by NHFTStated in progressThe respondent said that this action was in progress when they made their response on 18 March 2026.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.2

  1. Position

    The Trust cannot ensure notification of private psychiatric care because patients and private providers are not obliged to inform it.

    Stated by NHFTUnable 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 of notification pathways to ensure NHS mental health services are aware of private psychiatric treatment

Wider context from the report

“One of the findings of the Patient Safety Incident Investigation (PSII) was that “.. there is no protocol for patients open to private and NHS psychiatry at Northamptonshire Healthcare Foundation Trust. The Psychiatrist’s role in patient care is to review and recommend appropriate medication and it is problematic if two Consultants are overseeing this at the same time. It can cause confusion and detriment to the patient if medication changes are not communicated between parties and represents a risk to patient safety... It is notable that CMHT operational managers from across the service differ in their views on the appropriateness of a patient being open to NHS and private services at the same time..”. It also emerged at Inquest that a NHS Consultant may not be aware that the patient is also receiving private psychiatry. Where the GP is notified of private psychiatry, it does not trigger a notification to NHS mental health services. Notification of the dual treatment may then be entirely dependent upon the information being shared by the patient. ”

Is this part of a recurring concern?

Yes — Unreliable coordination and escalation between care providers and mental health services; Unreliable inter-agency information sharing for coordinated 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

Lack of a protocol for patients receiving concurrent private and NHS psychiatry

Wider context from the report

“One of the findings of the Patient Safety Incident Investigation (PSII) was that “.. there is no protocol for patients open to private and NHS psychiatry at Northamptonshire Healthcare Foundation Trust. The Psychiatrist’s role in patient care is to review and recommend appropriate medication and it is problematic if two Consultants are overseeing this at the same time. It can cause confusion and detriment to the patient if medication changes are not communicated between parties and represents a risk to patient safety... It is notable that CMHT operational managers from across the service differ in their views on the appropriateness of a patient being open to NHS and private services at the same time..”. It also emerged at Inquest that a NHS Consultant may not be aware that the patient is also receiving private psychiatry. Where the GP is notified of private psychiatry, it does not trigger a notification to NHS mental health services. Notification of the dual treatment may then be entirely dependent upon the information being shared by the patient. ”

Is this part of a recurring concern?

Yes — Failure to integrate mental health services across care settings; Unreliable coordination and escalation between care providers and mental health services.

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 medication changes between private and NHS psychiatric providers

Wider context from the report

“One of the findings of the Patient Safety Incident Investigation (PSII) was that “.. there is no protocol for patients open to private and NHS psychiatry at Northamptonshire Healthcare Foundation Trust. The Psychiatrist’s role in patient care is to review and recommend appropriate medication and it is problematic if two Consultants are overseeing this at the same time. It can cause confusion and detriment to the patient if medication changes are not communicated between parties and represents a risk to patient safety... It is notable that CMHT operational managers from across the service differ in their views on the appropriateness of a patient being open to NHS and private services at the same time..”. It also emerged at Inquest that a NHS Consultant may not be aware that the patient is also receiving private psychiatry. Where the GP is notified of private psychiatry, it does not trigger a notification to NHS mental health services. Notification of the dual treatment may then be entirely dependent upon the information being shared by the patient. ”

Is this part of a recurring concern?

Yes — Unreliable coordination and escalation between care providers and mental health services; Unreliable implementation of medication changes; Unreliable inter-specialty communication for complex patient care; Unsafe coordination of shared care.

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

Develop and complete a Trust-wide protocol for managing patients receiving simultaneous NHS and private psychiatric care.

Verbatim wording from the response

“Protocol for patients receiving NHS and private psychiatry Patient safety is of paramount importance to NHFT. We understand that there are risks to a patient’s safety when they are receiving private psychiatric care alongside our own treatment plan. To manage these risks, we are developing a new private care protocol.”

Source location

2026-0153 - Response from Northamptonshire Healthcare NHS Foundation Trust
Page 1 · response
Published 18 March 2026

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 Trust cannot ensure notification of private psychiatric care because patients and private providers are not obliged to inform it.

Verbatim wording from the response

“This new private care protocol will guide clinicians throughout the organisation on how to approach circumstances when it becomes known that their patient is accessing care from a private healthcare provider. It will operate within our existing policy framework, linked to existing policies and procedures for information sharing and record keeping. Work to develop this new protocol is underway and will be completed by the end of this month. Once in place it will apply to new and existing patients. Please let me know if you would like to receive a copy of the protocol and I shall arrange for it to be sent to you.”

Source location

2026-0153 - Response from Northamptonshire Healthcare NHS Foundation Trust
Page 2 · response
Published 18 March 2026

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 Integrated Care Board is responsible for confirming actions to encourage GPs to notify the Trust about concurrent private psychiatric care.

Verbatim wording from the response

“Sharing information when patients are accessing private psychiatry I note that you sent a copy of your Report to the Northamptonshire Integrated Care Board (NICB), as the body responsible for commissioning primary care services from GPs.”

Source location

2026-0153 - Response from Northamptonshire Healthcare NHS Foundation Trust
Page 2 · response
Published 18 March 2026

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