PFD report

Stuart Michael Campbell · Prevention of Future Deaths report

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Issued 30 Oct 2017•Manchester South

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
5

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

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 raised5

  1. Unclear documentation of shared care discussions
    Part of recurring concern: Unsafe coordination of shared care
  2. Unclear guidance available to ADS workers
  3. Unclear facilitation of shared care discussions
    Part 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.2

  1. Action

    Retrain all shared-care staff on the standard operating protocol, escalation procedures, and multidisciplinary shared-care discussions.

    Stated by Addiction Dependency SolutionsStated plannedThe respondent said that this action was planned when they made their response on 15 February 2018.
  2. Action

    Establish monthly medical and nursing clinical supervision for all three shared-care staff, including case reviews and clinical advice.

    Stated by Addiction Dependency SolutionsStated completedThe respondent said that this action was complete when they made their response on 15 February 2018.

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

Unclear documentation of shared care discussions

Wider context from the report

“2. Care was shared care between ADS and the GP. The GP had not seen the deceased and it was unclear how shared care discussions could be facilitated and documented. ”

Is this part of a recurring concern?

Yes — Unsafe coordination of shared 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

Unclear guidance available to ADS workers

Wider context from the report

“1. The inquest was told that ADS were the lead contractor for the provision of services. The protocol between ADS and Pennine Care had an escalation policy to be followed where an ADS worker felt the needs of an individual felt the needs could not be met via ADS. An escalation had not taken place in this case. It was unclear what guidance was available to ADS workers. There was no provision for clinical support for ADS workers. ”

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

Unclear facilitation of shared care discussions

Wider context from the report

“2. Care was shared care between ADS and the GP. The GP had not seen the deceased and it was unclear how shared care discussions could be facilitated and documented. ”

Is this part of a recurring concern?

Yes — Unsafe coordination of shared 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 escalate individuals’ unmet needs

Wider context from the report

“1. The inquest was told that ADS were the lead contractor for the provision of services. The protocol between ADS and Pennine Care had an escalation policy to be followed where an ADS worker felt the needs of an individual felt the needs could not be met via ADS. An escalation had not taken place in this case. It was unclear what guidance was available to ADS workers. There was no provision for clinical support for ADS workers. ”

Is this part of a recurring concern?

Yes — Unreliable escalation policy for care concerns.

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 clinical support for ADS workers

Wider context from the report

“1. The inquest was told that ADS were the lead contractor for the provision of services. The protocol between ADS and Pennine Care had an escalation policy to be followed where an ADS worker felt the needs of an individual felt the needs could not be met via ADS. An escalation had not taken place in this case. It was unclear what guidance was available to ADS workers. There was no provision for clinical support for ADS workers. ”

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

Retrain all shared-care staff on the standard operating protocol, escalation procedures, and multidisciplinary shared-care discussions.

Verbatim wording from the response

“19. As part of our detailed response to your concerns ADS will ensure that all our shared care staff receive additional training and re-training with regard to the standard operating protocol. We will re-train all staff in managing shared care and in the escalation procedure. This will also include specific guidance on multi-disciplinary shared care discussions. ADS will ensure that this re-training is completed by 20th December 2017.”

Source location

2017-0390-Response-by-Addiction-Dependency-Solutions
Page 4 · response
Published 15 February 2018

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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

Establish monthly medical and nursing clinical supervision for all three shared-care staff, including case reviews and clinical advice.

Verbatim wording from the response

“21. ADS has re-negotiated with the Pennine Care NHS Trust senior manager in Oldham One Recovery to provide ongoing clinical supervision via medical and nursing staff for all 3 ADS shared care staff on a monthly basis. This will ensure regular ongoing support for case reviews and discussions for clinical advice and planning with medical specialists from 30th November 2017.”

Source location

2017-0390-Response-by-Addiction-Dependency-Solutions
Page 4 · response
Published 15 February 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.4

  1. 1

    Commission organisation-wide Applied Suicide Intervention Skills Training in suicide first aid.

    Stated by Addiction Dependency SolutionsStated completedThe respondent said that this action was complete when they made their response on 15 February 2018.
  2. 2

    Have Oldham shared-care staff attend Applied Suicide Intervention Skills Training.

    Stated by Addiction Dependency SolutionsStated plannedThe respondent said that this action was planned when they made their response on 15 February 2018.
  3. 3

    Complete care-plan reviews for all 59 shared-care patients in the Failsworth and Royton clinics with local GPs or responsible medical officers.

    Stated by Addiction Dependency SolutionsStated plannedThe respondent said that this action was planned when they made their response on 15 February 2018.
  4. 4

    Cascade the prevention-of-future-deaths learning throughout ADS, share it with One Recovery subcontractors, and provide recommendations and actions to Oldham’s Suicide Prevention Working Group.

    Stated by Addiction Dependency SolutionsStated plannedThe respondent said that this action was planned when they made their response on 15 February 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

Commission organisation-wide Applied Suicide Intervention Skills Training in suicide first aid.

Verbatim wording from the response

“22. Furthermore, ADS has commissioned Applied Suicide Intervention Skills Training (ASIST) across the organisation. ASIST is a two-day interactive workshop in suicide first aid. It teaches participants to recognise when someone may have thoughts of suicide and work with them to create a plan that will support their immediate safety. Studies show that the ASIST methods help reduce suicidal feelings in those at risk and is a cost-effective way to help address the problem of suicide. It trains staff to the suicide alert - identify people who have thoughts of suicide. Understand the reasons behind thoughts of suicide and the reasons for living. Assess risk and safety - develop a plan to increase the safety of the person at risk of suicide. Recognise invitations for help and potential barriers of seeking help. Key ADS staff in Oldham who work in shared care will attend by December 31st 2017.”

Source location

2017-0390-Response-by-Addiction-Dependency-Solutions
Page 4 · response
Published 15 February 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

Have Oldham shared-care staff attend Applied Suicide Intervention Skills Training.

Verbatim wording from the response

“22. Furthermore, ADS has commissioned Applied Suicide Intervention Skills Training (ASIST) across the organisation. ASIST is a two-day interactive workshop in suicide first aid. It teaches participants to recognise when someone may have thoughts of suicide and work with them to create a plan that will support their immediate safety. Studies show that the ASIST methods help reduce suicidal feelings in those at risk and is a cost-effective way to help address the problem of suicide. It trains staff to the suicide alert - identify people who have thoughts of suicide. Understand the reasons behind thoughts of suicide and the reasons for living. Assess risk and safety - develop a plan to increase the safety of the person at risk of suicide. Recognise invitations for help and potential barriers of seeking help. Key ADS staff in Oldham who work in shared care will attend by December 31st 2017.”

Source location

2017-0390-Response-by-Addiction-Dependency-Solutions
Page 4 · response
Published 15 February 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

Complete care-plan reviews for all 59 shared-care patients in the Failsworth and Royton clinics with local GPs or responsible medical officers.

Verbatim wording from the response

“20. ADS will also undertake to carry out full care plan reviews with all shared care patients across the 2 full day clinics in Failsworth and Royton (59 patients in total) in conjunction with the local GP/RMOs and this will be completed by 31st March 2018.”

Source location

2017-0390-Response-by-Addiction-Dependency-Solutions
Page 4 · response
Published 15 February 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

Cascade the prevention-of-future-deaths learning throughout ADS, share it with One Recovery subcontractors, and provide recommendations and actions to Oldham’s Suicide Prevention Working Group.

Verbatim wording from the response

“will be cascaded throughout ADS via our Board of Trustees and via our Safeguarding and Effectiveness Committee and shared with all One Recovery sub-contractors. We will also undertake to share the recommendations and actions with Oldham’s Suicide Prevention Working Group.”

Source location

2017-0390-Response-by-Addiction-Dependency-Solutions
Page 5 · response
Published 15 February 2018

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