PFD report

Danyon Robert Chesters · Prevention of Future Deaths report

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Issued 26 Feb 2019•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
3

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
3

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 raised3

  1. Delays in accessing NHS mental health services
    Part of recurring concern: Excessive waiting times for NHS mental health services
  2. Lack of joined-up mental health care and information sharing between professionals
    Part of recurring concern: Insufficient multi-disciplinary coordination in mental health care
  3. Failure of private therapists to obtain information about mental health medication prescribing and its impact on therapy
    Part of recurring concern: Private mental-health providers failing to obtain relevant clinical information
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

    Invest in IAPT and expand community mental health services and access to psychological interventions in community and primary care.

    Stated by Department of Health and Social CareStated in progressThe respondent said that this action was in progress when they made their response on 9 June 2019.
  2. Action

    Expand IAPT services to increase access to psychological therapies for people with common mental health problems.

    Stated by Department of Health and Social CareStated plannedThe respondent said that this action was planned when they made their response on 9 June 2019.

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

  1. Position

    Local NHS bodies are responsible for commissioning psychological therapy services to meet their populations’ needs.

    Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking 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

Delays in accessing NHS mental health services

Wider context from the report

“1. Mr Chesters had previously sought help for Mental Health issues and had found significant delays in accessing services. Subsequently he had lived and worked in Germany. Whilst there he had been treated by German Mental Health Services. Following his return to England, he required further treatment. He saw his GP who indicated that there were significant delays in accessing Mental Health Services via the NHS. He felt this reflected his previous experiences with the NHS and that he could not wait and went to a private therapist. This expense caused him additional worry and he saw his therapist less regularly than would have been seen as the optimum frequency consequently. As a result of seeing a private therapist there was no joined up care in relation to his mental health and no information sharing between professionals involved in his care. ”

Is this part of a recurring concern?

Yes — Excessive waiting times for NHS mental health services.

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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 joined-up mental health care and information sharing between professionals

Wider context from the report

“1. Mr Chesters had previously sought help for Mental Health issues and had found significant delays in accessing services. Subsequently he had lived and worked in Germany. Whilst there he had been treated by German Mental Health Services. Following his return to England, he required further treatment. He saw his GP who indicated that there were significant delays in accessing Mental Health Services via the NHS. He felt this reflected his previous experiences with the NHS and that he could not wait and went to a private therapist. This expense caused him additional worry and he saw his therapist less regularly than would have been seen as the optimum frequency consequently. As a result of seeing a private therapist there was no joined up care in relation to his mental health and no information sharing between professionals involved in his care. ”

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

Failure of private therapists to obtain information about mental health medication prescribing and its impact on therapy

Wider context from the report

“2. The private therapist did not make further enquiries and did not show any curiosity about how he was being prescribed medication for his mental health condition. Private therapists do not appear to have any obligation to obtain information about prescribing of medication for mental health conditions or how that may impact the provision of therapy. ”

Is this part of a recurring concern?

Yes — Private mental-health providers failing to obtain relevant clinical information.

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

Invest in IAPT and expand community mental health services and access to psychological interventions in community and primary care.

Verbatim wording from the response

“As well as investing more in IAPT, we are supporting the NHS with an additional £2.3billion investment in real terms by 2023-24 in a comprehensive expansion of mental health services. Outlined in the NHS Long Term Plan³ published in January 2019, this includes an expansion of community services and better access to psychological interventions in the community and primary care.”

Source location

2019-0079-Response-by-Department-of-Health-and-Social-Care
Page 2 · response
Published 9 June 2019

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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

Expand IAPT services to increase access to psychological therapies for people with common mental health problems.

Verbatim wording from the response

“The Five Year Forward View for Mental Health² set out a commitment to expand IAPT services and improve quality further, with an ambition to increase access to psychological therapies for an additional 600,000 people with common mental health problems each year.”

Source location

2019-0079-Response-by-Department-of-Health-and-Social-Care
Page 2 · response
Published 9 June 2019

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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

Local NHS bodies are responsible for commissioning psychological therapy services to meet their populations’ needs.

Verbatim wording from the response

“It is the responsibility of the local NHS to commission services to meet the needs of their local populations. With regard to access to psychological therapies, one of the stated targets of the Improving Access to Psychological Therapies (IAPT) programme is that for new referrals, 75 per cent of people referred will enter treatment within six weeks, and 95 per cent within 18 weeks.”

Source location

2019-0079-Response-by-Department-of-Health-and-Social-Care
Page 2 · response
Published 9 June 2019

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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

    Set out suicide prevention and reduction recommendations for the NHS through national and cross-government suicide prevention plans.

    Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 9 June 2019.

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

Set out suicide prevention and reduction recommendations for the NHS through national and cross-government suicide prevention plans.

Verbatim wording from the response

“Suicide prevention is a key priority for this Government and we have set out clear recommendations to the NHS on suicide prevention and reduction in the National Suicide Prevention Strategy⁵ (2012), and the Cross-Government suicide prevention plan (2019)⁶. However, suicide prevention and reduction should be a priority for all who work with people with mental health problems, including counselling professionals. I am pleased to note that the British Association of Counselling and Psychotherapy has issued guidance to its members on ‘Working with Suicidal Clients in the Counselling professions’⁷.”

Source location

2019-0079-Response-by-Department-of-Health-and-Social-Care
Page 4 · response
Published 9 June 2019

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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