PFD report

Angela Catherine Brealey · Prevention of Future Deaths report

Pin Get email alerts Request correction

Issued 24 Dec 2015•Staffordshire 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.

View original report
Concerns
4

Raised in this report

Recipients
2

Named on the report

Responses found
1

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 raised4

  1. Serious incident reviews failing to identify treatment concerns
    Part of recurring concern: Inadequate safety incident investigationsPart of recurring concern: Unreliable formal safety-incident management processes
  2. Failure to protect confidentiality of information provided by third parties
  3. Insufficient involvement of a multi-disciplinary team in care
    Part of recurring concern: Insufficient multi-disciplinary coordination in mental health 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.4

  1. Action

    Implement a policy and process for receiving and storing third-party information in RiO, including uploading written communications and recording verbal communications.

    Stated by Midlands Partnership University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 24 December 2015.
  2. Action

    Review and amend the Serious Incident Review Process, with structured internal and external governance arrangements.

    Stated by Midlands Partnership University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 24 December 2015.
  3. Action

    Require commissioners to conduct a challenge review before signing serious incident reports for release.

    Stated by Midlands Partnership University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 24 December 2015.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.2

  1. Position

    Third-party information cannot be acknowledged where doing so would breach Caldicott confidentiality principles.

    Stated by Midlands Partnership University 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

Serious incident reviews failing to identify treatment concerns

Wider context from the report

“(3) Generally the serious incident review process is a very helpful one. In this particular case however a number of concerns about Angela’s treatment were not picked up by the review. Is pressure on those carrying out this process reducing the effectiveness of the reports? ”

Is this part of a recurring concern?

Yes — Inadequate safety incident investigations; Unreliable formal safety-incident management processes.

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 protect confidentiality of information provided by third parties

Wider context from the report

“(1) At the Inquest I heard various evidence about what should happen to information received from third parties concerning a person receiving treatment from the Trust. This does feature in the action plan prepared following the Inquest but I think the process should be looked at on quite a wide basis. Should information received from a third party be acknowledged at all? If so, how? How much of lengthy communications received from third parties should be recorded? Is entry on the RIO medical notes sufficient in itself? How is patient confidentiality protected in these circumstances and what about circumstances where third parties request confidentiality for information they have provided? ”

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

Insufficient involvement of a multi-disciplinary team in care

Wider context from the report

“(2) During the period that Angela was receiving assistance from the Trust there is minimal evidence of a multi-disciplinary team being involved. Predominantly one community mental health nurse took responsibility. While it may not have affected the outcome in this case a team approach involving a number of professionals may have been preferable. Is this something that the Trust needs to look at? ”

Is this part of a recurring concern?

Yes — Insufficient multi-disciplinary coordination in mental health 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

Lack of a defined process for acknowledging and recording information received from third parties

Wider context from the report

“(1) At the Inquest I heard various evidence about what should happen to information received from third parties concerning a person receiving treatment from the Trust. This does feature in the action plan prepared following the Inquest but I think the process should be looked at on quite a wide basis. Should information received from a third party be acknowledged at all? If so, how? How much of lengthy communications received from third parties should be recorded? Is entry on the RIO medical notes sufficient in itself? How is patient confidentiality protected in these circumstances and what about circumstances where third parties request confidentiality for information they have provided? ”

Is this part of a recurring concern?

Yes — Failure to reliably record safety information received from external organisations.

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

Implement a policy and process for receiving and storing third-party information in RiO, including uploading written communications and recording verbal communications.

Verbatim wording from the response

“The Trust now has a clear policy and process for receiving and storing third party information in Rio which is in line with national policy. Lengthy written communications are uploaded to RiO as sent, so are available to the care team and a note made in the progress notes to identify they have been stored and the location. Verbal communication is recorded in progress notes in line with policy.”

Source location

2015-0473-Response-by-South-Staffordshire-and-Shropshire-Healthcare-NHS-Trust
Page 2 · response
Published 24 December 2015

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 and amend the Serious Incident Review Process, with structured internal and external governance arrangements.

Verbatim wording from the response

“Thank you for your comments regarding the overall helpfulness of the Serious Incident Review Process. I can confirm that since the time of this specific Serious Incident Review, the process has been reviewed and amended. The Serious Incident Review Process follows a structured and robust process with internal and external governance arrangements in place.”

Source location

2015-0473-Response-by-South-Staffordshire-and-Shropshire-Healthcare-NHS-Trust
Page 3 · response
Published 24 December 2015

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

Require commissioners to conduct a challenge review before signing serious incident reports for release.

Verbatim wording from the response

“In addition the reports now go through an additional governance process in that our commissioners carry out a challenge review prior to signing the report off for release.”

Source location

2015-0473-Response-by-South-Staffordshire-and-Shropshire-Healthcare-NHS-Trust
Page 3 · response
Published 24 December 2015

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

Employ a full-time Serious Incident Review Co-ordinator and Administrator to support investigations and improve the quality of serious incident reports and reviews.

Verbatim wording from the response

“The Trust now employs full-time Serious Incident Review Co-ordinator and Administrator to support Investigating Officers in the review process. The Serious Incident Review Co-ordinator works within the Trust’s Quality and Risk Department to help improve processes that are used to ensure the quality production of reports relevant to serious incidents. They support Investigating Officers in the completion of Serious Incident Reports and Significant Event Reviews and are responsible for the completion of Chronological and concise reports. The Serious Incident Review Co-ordinator supports and encourages an open and fair approach to incident identification and investigation, supported by a learning culture.”

Source location

2015-0473-Response-by-South-Staffordshire-and-Shropshire-Healthcare-NHS-Trust
Page 3 · response
Published 24 December 2015

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

Third-party information cannot be acknowledged where doing so would breach Caldicott confidentiality principles.

Verbatim wording from the response

“The Trust may not respond to information from third parties as we adhere to Caldicott Principles in the management of all service user information. Where these principles would be breached the recipient of the information would not acknowledge, to the third party, that the service user was known to the service.”

Source location

2015-0473-Response-by-South-Staffordshire-and-Shropshire-Healthcare-NHS-Trust
Page 1 · response
Published 24 December 2015

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

Existing multidisciplinary team oversight and supervision are considered sufficient even when one professional delivers the care plan.

Verbatim wording from the response

“The Trust mental health teams are all multi-professional and the model of working within all teams is multi-disciplinary, the care and treatment provided to all service users is overseen by the teams so even in circumstances where a person may be receiving interventions associated with a care plan from a single professional the individual practitioner will be discussing the care with other members of the team in caseload and team supervision.”

Source location

2015-0473-Response-by-South-Staffordshire-and-Shropshire-Healthcare-NHS-Trust
Page 2 · response
Published 24 December 2015

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