PFD report

Amanda Jane Vickers · Prevention of Future Deaths report

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Issued 3 Feb 2014•North and West Cumbria

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
1

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
2

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 raised1

  1. Insufficient availability of crisis home beds
    Part of recurring concern: Insufficient and unsafe crisis-house provision for patients needing crisis 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 improved mental health pathways, including the configuration of community and bed-based crisis services across the county.

    Stated by NHS Cumbria Clinical Commissioning GroupStated plannedThe respondent said that this action was planned when they made their response on 3 February 2014.

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

Insufficient availability of crisis home beds

Wider context from the report

“This lady died whilst awaiting a place at 81 Lowther Street Crisis Home. She had been there before and found it therapeutic. No space was available, and no date when one might arise was known. She died whilst waiting for admission. The evidence was that this 6-bedded unit is the only one of its type in the whole county. It is understood that the CCG is responsible for commissioning such facilities. On the balance of probability an admission would have made a difference in this case. A review of the facilities available is suggested with a view to the provision of a greater number of beds for patients such as the deceased. ”

Is this part of a recurring concern?

Yes — Insufficient and unsafe crisis-house provision for patients needing crisis care.

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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

Develop improved mental health pathways, including the configuration of community and bed-based crisis services across the county.

Verbatim wording from the response

“The independent review of mental health is due to report back at the end of May 2014. This will inform the future provision of mental health and wellbeing strategy from 2014. This is with a view to developing a new Mental Health Strategy for our County and will have a significant impact on public/patient consultation. Both of these elements will have a significant impact in informing the development of improved mental health pathways which will include configuration of community and bed-based crisis services across the county.”

Source location

2014-0052-Response-by-Cumbria-Clinical-Commissioning-Group
Page 1 · response
Published 3 February 2014

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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.1

  1. 1

    Develop a new countywide Mental Health Strategy informed by the independent mental health review and public and patient consultation.

    Stated by NHS Cumbria Clinical Commissioning GroupStated plannedThe respondent said that this action was planned when they made their response on 3 February 2014.

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 a new countywide Mental Health Strategy informed by the independent mental health review and public and patient consultation.

Verbatim wording from the response

“The independent review of mental health is due to report back at the end of May 2014. This will inform the future provision of mental health and wellbeing strategy from 2014. This is with a view to developing a new Mental Health Strategy for our County and will have a significant impact on public/patient consultation. Both of these elements will have a significant impact in informing the development of improved mental health pathways which will include configuration of community and bed-based crisis services across the county.”

Source location

2014-0052-Response-by-Cumbria-Clinical-Commissioning-Group
Page 1 · response
Published 3 February 2014

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