PFD report

Marcus HANCE · Prevention of Future Deaths report

Pin Get email alerts Request correction

Issued 7 Jun 2018•Cornwall and Isles of Scilly

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
2

Of 2 recipients

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.

Open published report

Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised3

  1. Requirement for substance misuse treatment before mental health treatment
    Part of recurring concern: Unreliable dual-diagnosis care pathways
  2. Lack of access to mental health support for people with drug dependency
  3. Discharge from CMHT after two missed appointments
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.3

  1. Action

    Work in partnership with NHS Kernow on ongoing reviews of the Dual Diagnosis strategy, service interdependencies, and service specifications.

    Stated by Cornwall Partnership NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 8 July 2018.
  2. Action

    Review interdependencies between mental health and substance misuse services, refreshing referral, transition, risk management and information-sharing protocols.

    Stated by NHS Cornwall and the Isles of Scilly Integrated Care BoardStated in progressThe respondent said that this action was in progress when they made their response on 8 July 2018.
  3. Action

    Commence a formal review of service specifications, including the approach to non-attendance at mental health appointments.

    Stated by NHS Cornwall and the Isles of Scilly Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 8 July 2018.

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

  1. Position

    Cornwall Council leads commissioning of drug and alcohol services, assigning responsibility for that provision to another body.

    Stated by NHS Cornwall and the Isles of Scilly Integrated Care BoardRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking 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

Requirement for substance misuse treatment before mental health treatment

Wider context from the report

“(2) The approach to cases of dual diagnosis, that substance misuse should be addressed before any mental health treatment could proceed. ”

Is this part of a recurring concern?

Yes — Unreliable dual-diagnosis care 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 access to mental health support for people with drug dependency

Wider context from the report

“(1) Marcus was in a position where he was getting support with his drug dependency from the drug and alcohol team but was not able to access support for the mental health issues which were associated with the drug dependency. ”

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

Discharge from CMHT after two missed appointments

Wider context from the report

“(3) The discharge from CMHT on failing to attend two appointments. ”

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

Work in partnership with NHS Kernow on ongoing reviews of the Dual Diagnosis strategy, service interdependencies, and service specifications.

Verbatim wording from the response

“Thank you for providing me with the response provided by NHS Kernow Clinical Commissioning Group, commissioners of mental health services, confirming the on-going review in relation to the Dual Diagnosis strategy; the review of the interdependencies between Outlook Southwest and the Trust and the review of a number of service specifications between NHS Kernow and the Trust.”

Source location

2018-0173-Response-by-Cornwall-NHS-Trust
Page 1 · response
Published 8 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

Review interdependencies between mental health and substance misuse services, refreshing referral, transition, risk management and information-sharing protocols.

Verbatim wording from the response

“NHS Kernow are reviewing interdependencies between Outlook SW and Cornwall Partnership NHS Foundation Trust. This work includes a joint refresh of existing protocols in support of smooth referral pathways and transitions between services and different service lines, a review of risk management processes and information sharing arrangements. The intention is to conclude this work by December 2018.”

Source location

2018-0173-Kernow-NHS-Trust
Page 2 · response
Published 8 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

Commence a formal review of service specifications, including the approach to non-attendance at mental health appointments.

Verbatim wording from the response

“NHS Kernow and Cornwall Partnership NHS Foundation Trust have agreed to commence a formalised process to review a number of service specifications which will prioritise those services currently subject to transformation. This will include the approach taken in cases of non-attendance at mental health appointments,”

Source location

2018-0173-Kernow-NHS-Trust
Page 2 · response
Published 8 July 2018

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

Cornwall Council leads commissioning of drug and alcohol services, assigning responsibility for that provision to another body.

Verbatim wording from the response

“NHS Kernow are partners in the implementation of the existing Dual Diagnosis Strategy, along with DAAT commissioners and Cornwall Partnership NHS Foundation Trust. The strategy requires that at an operational and clinical level, services work together to ensure safe and seamless care for individual’s most affected. The Crisis Care Concordat multi-agency group, Chaired by the GP Clinical Lead for Mental Health, includes representation from the Drug and Alcohol Action Team (DAAT), and is reviewing its local action plans with a view to setting out revised actions associated with Dual Diagnosis. Cornwall Council are lead commissioners of drug and alcohol services, and there is a joint commitment to establish meaningful, equitable and sustainable service change and promote joint working across agencies.”

Source location

2018-0173-Kernow-NHS-Trust
Page 2 · response
Published 8 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.1

  1. 1

    Share learning and associated actions from the incident with partner organisations and national quality networks.

    Stated by NHS Cornwall and the Isles of Scilly Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 8 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

Share learning and associated actions from the incident with partner organisations and national quality networks.

Verbatim wording from the response

“NHS Kernow recognises the value of sharing the learning from serious incidents to the wider health community. The quality team will share the learning and associated actions related to this incident with our partners in Devon, Somerset and Dorset via our Community of Practice and with NHS England and NHS Improvement through our Quality Network.”

Source location

2018-0173-Kernow-NHS-Trust
Page 2 · response
Published 8 July 2018

Open published response
Back to top

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