PFD report

Sarah Elizabeth ADAMS · Prevention of Future Deaths report

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Issued 21 Mar 2024•Berkshire

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
3

Named on the report

Responses found
3

Of 3 recipients

Stated actions
17

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. Lack of training for practitioners in the discharge process, including issues arising from out of area admissions
    Part of recurring concern: Failure to ensure safe discharge planning for inpatient mental health admissionsPart of recurring concern: Out-of-area mental health placements failing to provide effective continuity of care and supportPart of recurring concern: Unreliable hospital discharge processes
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

    Develop and deploy discharge-policy induction slides covering checklists, risks, documentation and communication with community teams.

    Stated by Cygnet Health Care LimitedStated in progressThe respondent said that this action was in progress when they made their response on 3 April 2024.
  2. Action

    Update risk e-learning guidance to address risk assessment around discharge.

    Stated by Cygnet Health Care LimitedStated plannedThe respondent said that this action was planned when they made their response on 3 April 2024.
  3. Action

    Deliver face-to-face care planning and risk assessment training to the multidisciplinary team.

    Stated by Cygnet Health Care LimitedStated completedThe respondent said that this action was complete when they made their response on 3 April 2024.

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

  1. Position

    The existing discharge SOP applies regardless of admission location, and Adult Social Care practitioners are required to follow it.

    Stated by Reading Borough CouncilExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.

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 training for practitioners in the discharge process, including issues arising from out of area admissions

Wider context from the report

“That clinicians and other hospital, mental health Trust and Social Care practitioners involved in the discharge of patients from in-patient mental health admissions are not trained in the discharge process generally and specifically the issues which may arise in respect of out of area admissions ”

Is this part of a recurring concern?

Yes — Failure to ensure safe discharge planning for inpatient mental health admissions; Out-of-area mental health placements failing to provide effective continuity of care and support; Unreliable hospital discharge processes.

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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 and deploy discharge-policy induction slides covering checklists, risks, documentation and communication with community teams.

Verbatim wording from the response

“Further, a supplemental set of training slides for staff induction are in development to provide support to staff in understanding the content of the discharge policy, including the discharge checklist, the key risks to consider, accurate documentation and communication with community teams. These slides will be deployed by 1st June 2024 for all Cygnet Hospital sites to assist new staff with prompt familiarisation with our processes.”

Source location

Response from Cygnet Healthcare
Page 2 · response
Published 3 April 2024

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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

Update risk e-learning guidance to address risk assessment around discharge.

Verbatim wording from the response

“This training is aligned with Cygnet's broader training offering, particularly our e-learning risk training. This training is provided to all members of the MDT and refreshed on a two-yearly basis. The session provides guidance to staff in assessing risk, utilising the relevant tools and ensuring that risk assessments are of high quality and triangulated with the care plans, continuous notes and information from families and carers. We are acutely aware that risks can increase at discharge and that risk assessments need to be undertaken carefully to ensure that we implement steps to minimise this. The risk training has been reviewed and from 1 July 2024 will include updated and more specific guidance in relation to risk assessing around discharge.”

Source location

Response from Cygnet Healthcare
Page 1 · response
Published 3 April 2024

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

Deliver face-to-face care planning and risk assessment training to the multidisciplinary team.

Verbatim wording from the response

“Care planning and risk assessment training is provided to staff to support them in completing care plans, including discharge care plans. This is via a 4.5 hour face to face session. The session is provided by the Regional Nursing Director to all the Clinical Managers to then be cascaded at each site. At Cygnet Harrow this session has been provided to all members of the multi-disciplinary team (MDT) and is due to be refreshed on an annual basis, or more frequently if a need is identified.”

Source location

Response from Cygnet Healthcare
Page 1 · response
Published 3 April 2024

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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

Implement revised Clinical Risk training with increased focus on high-risk discharge situations.

Verbatim wording from the response

“All clinical staff in the Mental Health Divisions undertake Clinical Risk training which includes a focus on admission and discharge from inpatient services. We have now reviewed and revised this training offer across the organisation to ensure that moving forward there will be an increased focus on high-risk situations such as:”

Source location

Response from Berkshire Healthcare NHS Foundation Trust
Page 1 · response
Published 3 April 2024

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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 existing discharge SOP applies regardless of admission location, and Adult Social Care practitioners are required to follow it.

Verbatim wording from the response

“9. We confirm that all Adult Social Care practitioners involved in discharge planning are required to know and act in accordance with the SOP. Precise processes regarding discharge planning may differ from Trust to Trust.”

Source location

Response from Reading Borough Council
Page 2 · response
Published 3 April 2024

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.13

  1. 1

    Invite the Parliamentary and Health Ombudsman to discuss its findings on safe, patient-centred mental-health discharge.

    Stated by Cygnet Health Care LimitedStated plannedThe respondent said that this action was planned when they made their response on 3 April 2024.
  2. 2

    Introduce a Cygnet Social Worker role on Byron Ward to coordinate discharge arrangements and liaise with families and community services.

    Stated by Cygnet Health Care LimitedStated completedThe respondent said that this action was complete when they made their response on 3 April 2024.
  3. 3

    Commence a quality-improvement project exploring a working arrangement with the Samaritans for high-risk patients ready for discharge.

    Stated by Cygnet Health Care LimitedStated plannedThe respondent said that this action was planned when they made their response on 3 April 2024.
  4. 4

    Publish the revised discharge policy covering discharge processes.

    Stated by Cygnet Health Care LimitedStated completedThe respondent said that this action was complete when they made their response on 3 April 2024.
  5. 5

    Hold a Safer Discharge Conference addressing discharge risks, practical arrangements, communication and patient-centred processes.

    Stated by Cygnet Health Care LimitedStated plannedThe respondent said that this action was planned when they made their response on 3 April 2024.
  6. 6

    Update the discharge notification form to document post-discharge community support and its commencement date.

    Stated by Cygnet Health Care LimitedStated completedThe respondent said that this action was complete when they made their response on 3 April 2024.
  7. 7

    Capture and disseminate learning from the inquest through Cygnet Harrow representatives.

    Stated by Cygnet Health Care LimitedStated completedThe respondent said that this action was complete when they made their response on 3 April 2024.
  8. 8

    Run an enhanced group supervision process alongside Clinical Risk training to check that practice reflects expected standards.

    Stated by Berkshire Healthcare NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 3 April 2024.
  9. 9

    Strengthen discharge guidance, including additional guidance on the 72-hour follow-up process and patients who refuse follow-up.

    Stated by Berkshire Healthcare NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 3 April 2024.
  10. 10

    Provide a Caseload Coordinator role focused on CRHTT discharge planning, liaison, documentation, implementation and follow-up.

    Stated by Berkshire Healthcare NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 3 April 2024.
  11. 11

    Continue changing the Care Programme Approach process to coordinate discharge responsibility across multidisciplinary, social care and voluntary-sector organisations.

    Stated by Berkshire Healthcare NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 3 April 2024.
  12. 12

    Update pathways and links with Voluntary, Community and Social Enterprise organisations.

    Stated by Berkshire Healthcare NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 3 April 2024.
  13. 13

    Review caseloads and improve risk documentation and safety planning.

    Stated by Berkshire Healthcare NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 3 April 2024.

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

Invite the Parliamentary and Health Ombudsman to discuss its findings on safe, patient-centred mental-health discharge.

Verbatim wording from the response

“It is also planned to invite the Parliamentary and Health Ombudsman to discuss their recent findings and report "Discharge from mental health care: making it safe and patient-centred".”

Source location

Response from Cygnet Healthcare
Page 2 · response
Published 3 April 2024

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

Introduce a Cygnet Social Worker role on Byron Ward to coordinate discharge arrangements and liaise with families and community services.

Verbatim wording from the response

“Since this inquest Byron Ward now also has a Cygnet Social Worker. This role provides coordination of the discharge arrangements including liaison with family and community services which further assists with ensuring that discharges processes run smoothly. Cygnet Health Care takes the care and safety of its patients extremely seriously and is continuously working to improve its practice to provide the highest possible standard of care. Representatives from Cygnet Harrow were present in court throughout the inquest to ensure that the learning from this matter was captured and disseminated. I hope that this response provides some measure of reassurance to HM Assistant Coroner and Ms Adams’ family.”

Source location

Response from Cygnet Healthcare
Page 2 · response
Published 3 April 2024

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 quality-improvement project exploring a working arrangement with the Samaritans for high-risk patients ready for discharge.

Verbatim wording from the response

“On 1 June 2024 we will commence a quality improvement project in relation to the learning from this inquest, this will look at exploring a working arrangement with the Samaritans. This would provide for any high risk patients ready for discharge to be, with their consent, referred to the Samaritans. The Samaritans would then contact the discharged patients within 24 hours and if they have any concerns they can take appropriate action. This model has been successfully utilised in other mental health organisations and can bridge the gap between discharge and being reviewed by their community teams providing an additional risk mitigation and safeguard on discharge.”

Source location

Response from Cygnet Healthcare
Page 2 · response
Published 3 April 2024

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

Publish the revised discharge policy covering discharge processes.

Verbatim wording from the response

“Discharge arrangements are specific to each individual who is being discharged and Cygnet needs to be flexible as it discharges to multiple different community organisations. To ensure that our processes are consistent and nothing is missed Cygnet has detailed policies covering the discharge processes. The new discharge policy was reviewed and published March 2024.”

Source location

Response from Cygnet Healthcare
Page 1 · response
Published 3 April 2024

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

Hold a Safer Discharge Conference addressing discharge risks, practical arrangements, communication and patient-centred processes.

Verbatim wording from the response

“In addition, our Group Medical Director is arranging a Safer Discharge Conference planned to go ahead in Summer 2024. The learning conference will look at specific risks associated with discharge and the practical arrangements surrounding discharge. Our stakeholders, including community mental health teams and Local Authority Adult Social Care Teams, will be invited to this conference to share actions taken to improve discharge processes, checklists, policies and improved communication with a focus on patient centredness and to ensure that our commissioners and collaborators are aware of our processes and what role they will undertake in the discharge process. The conference will include panel discussions that involve carers and Expert by Experience leads.”

Source location

Response from Cygnet Healthcare
Page 2 · response
Published 3 April 2024

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

Update the discharge notification form to document post-discharge community support and its commencement date.

Verbatim wording from the response

“This policy was benchmarked with a large mental health Trust to ensure we had the best evidence and our policies were in line with those of the sector. The documentation to support discharge includes the discharge notification form which was also updated in March 2024 to specifically highlight the need to document the plan for post-discharge community support, including when this support will commence. This form is shared with the patient and all relevant stakeholders on discharge to ensure that all relevant agencies are aware of the agreed plan. Cygnet also utilises a discharge checklist which must be completed by the Responsible Clinician for every discharge.”

Source location

Response from Cygnet Healthcare
Page 2 · response
Published 3 April 2024

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

Capture and disseminate learning from the inquest through Cygnet Harrow representatives.

Verbatim wording from the response

“Since this inquest Byron Ward now also has a Cygnet Social Worker. This role provides coordination of the discharge arrangements including liaison with family and community services which further assists with ensuring that discharges processes run smoothly. Cygnet Health Care takes the care and safety of its patients extremely seriously and is continuously working to improve its practice to provide the highest possible standard of care. Representatives from Cygnet Harrow were present in court throughout the inquest to ensure that the learning from this matter was captured and disseminated. I hope that this response provides some measure of reassurance to HM Assistant Coroner and Ms Adams’ family.”

Source location

Response from Cygnet Healthcare
Page 2 · response
Published 3 April 2024

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

Run an enhanced group supervision process alongside Clinical Risk training to check that practice reflects expected standards.

Verbatim wording from the response

“These modifications to the Clinical Risk training and guidance further strengthens the training already in place which complies with national guidance. It aims to enhance staff knowledge and skills by providing additional guidance and clarity on the importance of defining, agreeing, and clearly communicating roles, responsibilities, and timelines. The new Clinical Risk training starts on 1 May 2024. An enhanced group”

Source location

Response from Berkshire Healthcare NHS Foundation Trust
Page 1 · response
Published 3 April 2024

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

Strengthen discharge guidance, including additional guidance on the 72-hour follow-up process and patients who refuse follow-up.

Verbatim wording from the response

“• 72 hour follow up process.”

Source location

Response from Berkshire Healthcare NHS Foundation Trust
Page 1 · response
Published 3 April 2024

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

Provide a Caseload Coordinator role focused on CRHTT discharge planning, liaison, documentation, implementation and follow-up.

Verbatim wording from the response

“Our Crisis Response Home Treatment Team (CRHTT) have a Caseload Coordinator role who has a focus on CRHTT discharge planning. They are responsible for the liaison between the host ward (whether out of area or local) and transition into CRHTT where appropriate. They ensure that agreed discharge plans and actions for CRHTT are clear at the point of discharge and are documented, implemented, and followed up.”

Source location

Response from Berkshire Healthcare NHS Foundation Trust
Page 2 · response
Published 3 April 2024

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

Continue changing the Care Programme Approach process to coordinate discharge responsibility across multidisciplinary, social care and voluntary-sector organisations.

Verbatim wording from the response

“Finally, more broadly, the Care Programme Approach (CPA) process is presently in the process of changing, in line with guidance from NHS England and the national Community Mental Health Framework. The aim is to ensure that everyone receives the same level of care, including a named key worker for all service users but with a multidisciplinary approach that must be integrated with social care and the voluntary, community and social enterprise. Every member of the MDT will play a prominent role in sharing responsibility for an individual’s care, and it will be the MDT playing the coordinating role across the various organisations and sectors. This will include the responsibility for discharges from inpatient settings.”

Source location

Response from Berkshire Healthcare NHS Foundation Trust
Page 2 · response
Published 3 April 2024

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

Update pathways and links with Voluntary, Community and Social Enterprise organisations.

Verbatim wording from the response

“Significant work has been undertaken to review caseloads, improve risk documentation and safety planning as well as updating pathways and links with Voluntary, Community and Social Enterprise organisations.”

Source location

Response from Berkshire Healthcare NHS Foundation Trust
Page 2 · response
Published 3 April 2024

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 caseloads and improve risk documentation and safety planning.

Verbatim wording from the response

“Significant work has been undertaken to review caseloads, improve risk documentation and safety planning as well as updating pathways and links with Voluntary, Community and Social Enterprise organisations.”

Source location

Response from Berkshire Healthcare NHS Foundation Trust
Page 2 · response
Published 3 April 2024

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