PFD report

Tony Montana Duncan · Prevention of Future Deaths report

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Issued 15 Oct 2025•City of London

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
6

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
7

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 raised6

  1. Failure to recognise and assess an identified suicide risk
    Part of recurring concern: Inadequate mental health risk assessmentPart of recurring concern: Unreliable assessment of suicide and self-harm risk
  2. Failure to alert relevant services, the GP, or family about a high-risk patient’s departure
    Part of recurring concern: Failure to communicate clinically important information reliably between care servicesPart of recurring concern: Failure to communicate safety-critical care information effectively between care providers and familiesPart of recurring concern: Failure to escalate safety concerns after a high-risk patient leaves hospitalPart of recurring concern: Failure to reliably notify primary care of changes affecting patient care
  3. Failure to involve Crisis or Home Treatment teams for immediate safeguarding follow-up
    Part of recurring concern: Failure to act appropriately on safeguarding referrals and noticesPart of recurring concern: Unreliable community Home Treatment Team care 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

    Conduct multiple daily multidisciplinary clinical safety huddles in the emergency department to review risks and coordinate care.

    Stated by South London and Maudsley NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 20 October 2025.
  2. Action

    Operate a 24/7 Emergency Department Low Intensity Area at King’s College Hospital with capacity for six patients.

    Stated by South London and Maudsley NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 20 October 2025.
  3. Action

    Embed documented carer-contact prompts in the Liaison Psychiatry departmental handover board before discharge.

    Stated by South London and Maudsley NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 20 October 2025.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.6

  1. Position

    Family contact may not be possible if a capacitated patient refuses permission, although the refusal should be documented.

    Stated by South London and Maudsley NHS Foundation TrustUnable 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 recognise and assess an identified suicide risk

Wider context from the report

“2. When the Deceased attended the hospital, the Accident and Emergency team’s triage notes included express reference to his specific suicide plan and attached the GP’s letter of referral. The Deceased was then assessed by a psychiatric liaison nurse who concluded that his presentation was as a result of psycho-social stressors rather than mental illness; she was not concerned about the risk of suicide because he had no plan or intent; and she referred the Deceased to the homelessness team and discharged him back to the care of his GP. The nurse did not take any steps to review the Deceased’s medication or consider admission, or escalate these matters to a doctor, nor did she involve the Crisis or Home Treatment teams for follow up / immediate safeguarding. Despite there being a recognised risk to self and to others, both of which the Deceased himself said he could not control, there is no evidence of any risk assessment documentation being completed. ”

Is this part of a recurring concern?

Yes — Inadequate mental health risk assessment; Unreliable assessment of suicide and self-harm risk.

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 alert relevant services, the GP, or family about a high-risk patient’s departure

Wider context from the report

“3. The Deceased was subsequently seen in the Accident and Emergency Department by a Social Worker from the homelessness team. The Deceased insisted that he was not homeless and that he had attended the hospital for help with his mental health, without which he would jump from London Bridge. The Social Worker immediately passed this information to members of the psychiatric liaison team who he found, together, in their office. Subsequently, whilst still in the department, the Deceased became agitated and abusive, which behaviour was a recognised aspect of his behaviour when he was unwell. It seems he later left the department and/or was escorted out as he was being abusive; the records show that at least one member of the psychiatric liaison team was aware of this development but took no action to prevent the Deceased from leaving or to encourage him to stay in order to re-assess him, nor to alert the Crisis and/or Home Treatment teams, the GP, or the Deceased’s family as to the situation. ”

Is this part of a recurring concern?

Yes — Failure to communicate clinically important information reliably between care services; Failure to communicate safety-critical care information effectively between care providers and families; Failure to escalate safety concerns after a high-risk patient leaves hospital; Failure to reliably notify primary care of changes affecting patient 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 involve Crisis or Home Treatment teams for immediate safeguarding follow-up

Wider context from the report

“2. When the Deceased attended the hospital, the Accident and Emergency team’s triage notes included express reference to his specific suicide plan and attached the GP’s letter of referral. The Deceased was then assessed by a psychiatric liaison nurse who concluded that his presentation was as a result of psycho-social stressors rather than mental illness; she was not concerned about the risk of suicide because he had no plan or intent; and she referred the Deceased to the homelessness team and discharged him back to the care of his GP. The nurse did not take any steps to review the Deceased’s medication or consider admission, or escalate these matters to a doctor, nor did she involve the Crisis or Home Treatment teams for follow up / immediate safeguarding. Despite there being a recognised risk to self and to others, both of which the Deceased himself said he could not control, there is no evidence of any risk assessment documentation being completed. ”

Is this part of a recurring concern?

Yes — Failure to act appropriately on safeguarding referrals and notices; Unreliable community Home Treatment Team 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

Failure to document risk assessments

Wider context from the report

“2. When the Deceased attended the hospital, the Accident and Emergency team’s triage notes included express reference to his specific suicide plan and attached the GP’s letter of referral. The Deceased was then assessed by a psychiatric liaison nurse who concluded that his presentation was as a result of psycho-social stressors rather than mental illness; she was not concerned about the risk of suicide because he had no plan or intent; and she referred the Deceased to the homelessness team and discharged him back to the care of his GP. The nurse did not take any steps to review the Deceased’s medication or consider admission, or escalate these matters to a doctor, nor did she involve the Crisis or Home Treatment teams for follow up / immediate safeguarding. Despite there being a recognised risk to self and to others, both of which the Deceased himself said he could not control, there is no evidence of any risk assessment documentation being completed. ”

Is this part of a recurring concern?

Yes — Unreliable documentation of safety risk assessments; Unreliable recording of safety-critical mental health information.

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 review medication, consider admission, or escalate care for an acutely deteriorating patient

Wider context from the report

“2. When the Deceased attended the hospital, the Accident and Emergency team’s triage notes included express reference to his specific suicide plan and attached the GP’s letter of referral. The Deceased was then assessed by a psychiatric liaison nurse who concluded that his presentation was as a result of psycho-social stressors rather than mental illness; she was not concerned about the risk of suicide because he had no plan or intent; and she referred the Deceased to the homelessness team and discharged him back to the care of his GP. The nurse did not take any steps to review the Deceased’s medication or consider admission, or escalate these matters to a doctor, nor did she involve the Crisis or Home Treatment teams for follow up / immediate safeguarding. Despite there being a recognised risk to self and to others, both of which the Deceased himself said he could not control, there is no evidence of any risk assessment documentation being completed. ”

Is this part of a recurring concern?

Yes — Failure to escalate significant clinical concerns to appropriately senior clinicians; Failure to recognise and respond to deteriorating mental health in service users; Failure to reliably conduct clinically required medication reviews.

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 retain and re-assess a high-risk patient before departure

Wider context from the report

“3. The Deceased was subsequently seen in the Accident and Emergency Department by a Social Worker from the homelessness team. The Deceased insisted that he was not homeless and that he had attended the hospital for help with his mental health, without which he would jump from London Bridge. The Social Worker immediately passed this information to members of the psychiatric liaison team who he found, together, in their office. Subsequently, whilst still in the department, the Deceased became agitated and abusive, which behaviour was a recognised aspect of his behaviour when he was unwell. It seems he later left the department and/or was escorted out as he was being abusive; the records show that at least one member of the psychiatric liaison team was aware of this development but took no action to prevent the Deceased from leaving or to encourage him to stay in order to re-assess him, nor to alert the Crisis and/or Home Treatment teams, the GP, or the Deceased’s family as to the situation. ”

Is this part of a recurring concern?

Yes — Failure to escalate safety concerns after a high-risk patient leaves hospital.

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

Conduct multiple daily multidisciplinary clinical safety huddles in the emergency department to review risks and coordinate care.

Verbatim wording from the response

“Since Mr Duncan’s death the Trust has introduced several new systems to address the challenges raised by patients presenting to ED. The Liaison Psychiatry team carries out multiple clinical safety huddles in ED each day. These are brief, daily, multi-disciplinary team meetings to quickly review patient safety, share urgent information, identify risks (like high-risk behaviour or medication issues), plan care, improve teamwork, and resolve problems. This follows the team handover which facilitates rapid risk review and shared decision making between ED and Liaison Psychiatry teams.”

Source location

Response from South London and Maudsley NHS Foundation Trust
Page 7 · response
Published 20 October 2025

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

Operate a 24/7 Emergency Department Low Intensity Area at King’s College Hospital with capacity for six patients.

Verbatim wording from the response

“KCH has also launched a new ED Low Intensity Area (LIA) in partnership with SLAM. The LIA space offers a calm and supportive environment for suitable patients who would otherwise wait in the busy environment of the main ED. Operating 24/7, it currently has capacity for six patients. The LIA is a continuum of the ED, but patients are kept in a less stimulating environment. Patients who are moved into LIA have already been assessed and have a plan in place, but they need to wait to have it enacted. These plans may include referral for a psychiatric admission, referral to an associated team such as the homeless team or addictions care team, with ongoing care planning following the assessment, or referral to Recovery House in Lewisham, where they can be offered a maximum of 7 nights stay, as an alternative to admission for people who feel unable to return home.”

Source location

Response from South London and Maudsley NHS Foundation Trust
Page 7 · response
Published 20 October 2025

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

Embed documented carer-contact prompts in the Liaison Psychiatry departmental handover board before discharge.

Verbatim wording from the response

“Ideally, the PLN would have sought Mr Duncan’s consent to contact a named person/carer, ideally his mother with whom he lived, but did not do this; the AAR has made a recommendation to address this omission by embedding ‘carer contact’ in the Liaison Psychiatry departmental handover board; this must be done and documented before patients can be discharged. The Trust is accredited under the Triangle of Care initiative led by the Carers Trust and endorsed by NHS England, which seeks to implement six key standards required to achieve better collaboration and partnership with carers, including identification of carers at first contact; the implementation of this in the ED can be difficult for reasons outlined in the AAR, and this extra flag is intended to provide further operational support for future patient cases.”

Source location

Response from South London and Maudsley NHS Foundation Trust
Page 5 · response
Published 20 October 2025

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

Participate in the national Culture of Care Programme pilot on personalised approaches to suicide risk.

Verbatim wording from the response

“Training on personalised risk assessment and management was released by NHSE in September 2025, and the AAR recommends that such training should be mandatory for clinicians. The Trust is one of ten mental health organisations taking part in a national pilot through the NHS England and Royal College of Psychiatrists Culture of Care Programme – Personalised Approach to Risk. The pilot aims to enhance how we approach, assess, and manage the risk of suicide. This work aligns with the NICE guidance for Self-harm, which states that risk assessment tools should not be used to predict suicide. Further information can be found here: Culture of Care Programme and here: NCISH | Implementing a personalised approach to risk.”

Source location

Response from South London and Maudsley NHS Foundation Trust
Page 6 · response
Published 20 October 2025

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

Family contact may not be possible if a capacitated patient refuses permission, although the refusal should be documented.

Verbatim wording from the response

“The AAR did note that adult patients with mental capacity to make the relevant decision may well decline or refuse a request to contact their family, but in this case there is no documentation that this discussion took place. Family members are often able to provide useful collateral information which can assist in care planning, even if the patient does not permit the clinician to share information about them. However, if a patient refuses to allow contact, it may not be possible to make this contact. This should be noted in the electronic record.”

Source location

Response from South London and Maudsley NHS Foundation Trust
Page 5 · response
Published 20 October 2025

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

Doctor referral was not initially indicated because the established pathway covered admission, medication changes and other clinical complexities, with senior psychiatric doctors available continuously.

Verbatim wording from the response

“Referral by the PLN to a doctor was not clearly indicated, as this pathway is for those who may require admission under the Mental Health Act, or changes to their medication, or for other complexities as deemed by the assessing clinician. The AAR explored onward referral to doctors by PLNs and this was thought to be working well, with senior psychiatric doctors available 24 hours a day. Mr Duncan initially presented as calm and without signs or symptoms of affective disorder or psychosis. Later, when Mr Duncan became agitated, referral to a doctor to consider next steps (including potential referral to a crisis team) may have been indicated, and his self-discharge without further review or discussion was a lost opportunity to review the assessment and offer further support.”

Source location

Response from South London and Maudsley NHS Foundation Trust
Page 5 · response
Published 20 October 2025

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

Recovery House was unsuitable for homeless patients and therefore unavailable as an alternative to admission in this case.

Verbatim wording from the response

“KCH has also launched a new ED Low Intensity Area (LIA) in partnership with SLAM. The LIA space offers a calm and supportive environment for suitable patients who would otherwise wait in the busy environment of the main ED. Operating 24/7, it currently has capacity for six patients. The LIA is a continuum of the ED, but patients are kept in a less stimulating environment. Patients who are moved into LIA have already been assessed and have a plan in place, but they need to wait to have it enacted. These plans may include referral for a psychiatric admission, referral to an associated team such as the homeless team or addictions care team, with ongoing care planning following the assessment, or referral to Recovery House in Lewisham, where they can be offered a maximum of 7 nights stay, as an alternative to admission for people who feel unable to return home.”

Source location

Response from South London and Maudsley NHS Foundation Trust
Page 7 · response
Published 20 October 2025

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 patient with capacity could not lawfully be detained or prevented from leaving when insisting on self-discharge.

Verbatim wording from the response

“Had Mr Duncan been found to have capacity to make decisions around treatment and care, as he was in the initial assessment, there would have been no grounds to detain him and stop him if he insisted on leaving. However, it would have been useful to review his mental state again, given that his presentation appeared to change while he was in the ED. It does not appear that the Liaison Psychiatry team were informed by the ED team that Mr Duncan was trying to leave the ED and self-discharge, until such time as he was being escorted out by security. The AAR recommends that potential self-discharges must be flagged to the Liaison Psychiatry Team by Emergency Department colleagues early and there must be consideration whether further assessment is warranted to ensure self-discharge is safe.”

Source location

Response from South London and Maudsley NHS Foundation Trust
Page 5 · response
Published 20 October 2025

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

Medication discontinuation was not clearly the main cause of relapse, and the presentation did not indicate medication review by liaison psychiatry.

Verbatim wording from the response

“It is not clear discontinuation of medication was the main causative factor in Mr Duncan’s relapse as one might suspect in a psychotic illness. During the Psychiatric Liaison Nurse’s (PLN) assessment in KCH Emergency Department (ED), Mr Duncan did not present with signs or symptoms of psychotic or mood disorder, or with agitation or sleep disturbance which might indicate the need for medication. We acknowledge the GP requested a medication review in the referral letter and that the PLN did not address this. Medication review is often more usefully carried out with a full treatment history, and this is more suitable for the Community Mental”

Source location

Response from South London and Maudsley NHS Foundation Trust
Page 3 · response
Published 20 October 2025

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

Admission was not clearly beneficial for this condition, so community treatment was considered an appropriate alternative when the patient initially engaged.

Verbatim wording from the response

“Mr Duncan had last been admitted to hospital in 2016; this was initially a voluntary admission, subsequently an emergency Section 5(2) was used to detain him until a full Mental Health Act assessment could be organised. He was found not to be detainable and self-discharged against medical advice. Shortly after this he requested to be readmitted and when this could not be accommodated, he caused damage to Trust property by smashing the windows of the ward. When in the community, he was less agitated than on the ward and was subsequently managed by a CMHT and then primary care without further intervention from acute services. It is therefore not clear admission had been helpful, and this is not uncommon in patients with personality disorder and one of the reasons why the benefits of admission should be weighed against potential harms of admission to hospital.”

Source location

Response from South London and Maudsley NHS Foundation Trust
Page 4 · response
Published 20 October 2025

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.3

  1. 1

    Complete a retrospective After-Action Review of King’s College Hospital Liaison Psychiatry care.

    Stated by South London and Maudsley NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 20 October 2025.
  2. 2

    Develop and open a dedicated mental health urgent and emergency care centre at The Maudsley Hospital.

    Stated by South London and Maudsley NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 20 October 2025.
  3. 3

    Review governance arrangements for After-Action Reviews involving multiple directorates.

    Stated by South London and Maudsley NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 20 October 2025.

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

Complete a retrospective After-Action Review of King’s College Hospital Liaison Psychiatry care.

Verbatim wording from the response

“College Hospital Liaison Psychiatry. In accordance with Trust mortality processes, a mortality review had been carried out, and the incident had been referred for an After-Action Review (AAR), which is the Trust’s main investigatory response to a patient safety incident. However, the AAR spanned two boroughs and was taken forward by Lambeth Governance Team with no representation from Southwark. This was an oversight and meant that the AAR did not focus on learning from the parts of Mr Duncan’s care which had been provided by the King’s College Hospital (KCH) Liaison Psychiatry team, which is a service in the Southwark Directorate. Governance arrangements for AARs have been discussed at the Trust Patient Safety Committee on 13th November 2025 and are being reviewed.”

Source location

Response from South London and Maudsley NHS Foundation Trust
Page 3 · response
Published 20 October 2025

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

Develop and open a dedicated mental health urgent and emergency care centre at The Maudsley Hospital.

Verbatim wording from the response

“The AAR recognises the difficulties of providing optimum mental health care in the ED environment and makes a recommendation around the development and opening of a dedicated mental health urgent & emergency care (UEC) centre at The Maudsley Hospital. This had already been planned for June 2026. The model is designed around time, space, privacy, and dignity, permitting clinicians to formulate care and treatment plans collaboratively with patients and carers. A growing evidence base supports the model. The available evidence shows these deliver improved patient and staff experience; reduce 12-hour breaches in ED; and alleviate wider ED activity. SLAM has therefore developed this service with support from South East London Integrated Care Board (SEL ICB).”

Source location

Response from South London and Maudsley NHS Foundation Trust
Page 7 · response
Published 20 October 2025

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 governance arrangements for After-Action Reviews involving multiple directorates.

Verbatim wording from the response

“College Hospital Liaison Psychiatry. In accordance with Trust mortality processes, a mortality review had been carried out, and the incident had been referred for an After-Action Review (AAR), which is the Trust’s main investigatory response to a patient safety incident. However, the AAR spanned two boroughs and was taken forward by Lambeth Governance Team with no representation from Southwark. This was an oversight and meant that the AAR did not focus on learning from the parts of Mr Duncan’s care which had been provided by the King’s College Hospital (KCH) Liaison Psychiatry team, which is a service in the Southwark Directorate. Governance arrangements for AARs have been discussed at the Trust Patient Safety Committee on 13th November 2025 and are being reviewed.”

Source location

Response from South London and Maudsley NHS Foundation Trust
Page 3 · response
Published 20 October 2025

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