PFD report

Matthew George Kaliniecki WILLIAMSON · Prevention of Future Deaths report

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Issued 15 Oct 2019•West London

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
3

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
12

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. Failure of mental health providers to maintain clear inter-provider coordination
  2. Lack of opportunity for carers and family members to provide pertinent information to clinical mental health teams
  3. Absence of a patient roadmap for access to and type of treatment
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.6

  1. Action

    Amend operational policies to strengthen family involvement, manage cases where consent is withheld, and adopt Triangle of Care principles.

    Stated by West London NHS TrustStated completedThe respondent said that this action was complete when they made their response on 17 November 2019.
  2. Action

    Implement Triangle of Care standards across Trust services and submit regular progress reports to the Carers Trust.

    Stated by West London NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 17 November 2019.
  3. Action

    Operate the Trust Single Point of Access to process referrals and provide 24/7 mental health support and signposting.

    Stated by West London NHS TrustStated completedThe respondent said that this action was complete when they made their response on 17 November 2019.

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 mental health providers to maintain clear inter-provider coordination

Wider context from the report

“There appears to be a lack of opportunity for carers and family members to provide more pertinent information to clinical mental health teams and the interplay between mental health providers isn’t clear. This makes it very difficult to navigate as there is no patient road map which would assist with access to and type of treatment. ”

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

Lack of opportunity for carers and family members to provide pertinent information to clinical mental health teams

Wider context from the report

“There appears to be a lack of opportunity for carers and family members to provide more pertinent information to clinical mental health teams and the interplay between mental health providers isn’t clear. This makes it very difficult to navigate as there is no patient road map which would assist with access to and type of treatment. ”

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

Absence of a patient roadmap for access to and type of treatment

Wider context from the report

“There appears to be a lack of opportunity for carers and family members to provide more pertinent information to clinical mental health teams and the interplay between mental health providers isn’t clear. This makes it very difficult to navigate as there is no patient road map which would assist with access to and type of treatment. ”

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

Amend operational policies to strengthen family involvement, manage cases where consent is withheld, and adopt Triangle of Care principles.

Verbatim wording from the response

“• Amendment of operational policies to include sections on strengthening family involvement; managing cases where consent is not given; and the adoption of the Triangle of Care.”

Source location

2019-0349-Response-from-West-London-NHS-Trust-Redacted
Page 5 · response
Published 17 November 2019

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

Implement Triangle of Care standards across Trust services and submit regular progress reports to the Carers Trust.

Verbatim wording from the response

“21. The Trust is a formal member of the ‘Triangle of Care’ membership scheme, and we have committed to implementing the standards set out in the ‘Triangle of Care’. Part of this includes submitting regular progress reports to the Carers Trust. Progress reports for each stage of implementing the ‘Triangle of Care’ (Stage 1 and Stage 2) are expected. At West London NHS Trust, ‘Stage 1’ is the roll out of self-assessments throughout our inpatient services and crisis teams, and ‘Stage 2’ is the roll out of self-assessments throughout community services. We are currently considering whether a further stage is required for our community physical health services.”

Source location

2019-0349-Response-from-West-London-NHS-Trust-Redacted
Page 4 · response
Published 17 November 2019

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

Operate the Trust Single Point of Access to process referrals and provide 24/7 mental health support and signposting.

Verbatim wording from the response

“9. Specifically, as it is often GPs who will see patients with a range of mental health difficulties and who will then refer patients needing mental health services, we have established the Trust Single Point of Access (SPA) to support both GP referrals, and to help signpost people in need who have chosen not to see a GP, or who are unable to see a GP.”

Source location

2019-0349-Response-from-West-London-NHS-Trust-Redacted
Page 2 · response
Published 17 November 2019

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 Ealing Primary Care Mental Health Service staff with Carer Awareness and Triangle of Care training.

Verbatim wording from the response

“• Ealing PCMHS staff must attend Carer Awareness and Triangle of Care training sessions.”

Source location

2019-0349-Response-from-West-London-NHS-Trust-Redacted
Page 5 · response
Published 17 November 2019

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

Transform community services into integrated primary and secondary mental health teams aligned with Primary Care Networks and remove service boundaries.

Verbatim wording from the response

“17. As a result of this new framework, West London NHS Trust services are in the process of transforming to a series of integrated primary and secondary mental health teams, wrapped around the Primary Care Networks. Our new service will offset the need for criteria to be met to access a more intensive input at times of increased mental health need, and will ensure that boundaries between services are removed.”

Source location

2019-0349-Response-from-West-London-NHS-Trust-Redacted
Page 3 · response
Published 17 November 2019

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 managerial, clinical and carer support for embedding Triangle of Care practices in day-to-day work.

Verbatim wording from the response

“24. In order to continue towards Stage 2 and beyond, the Trust has identified the following areas for development:”

Source location

2019-0349-Response-from-West-London-NHS-Trust-Redacted
Page 4 · response
Published 17 November 2019

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.6

  1. 1

    Maintain a Triangle of Care project delivery plan and risk log, with regular updates reported through Trust governance meetings.

    Stated by West London NHS TrustStated completedThe respondent said that this action was complete when they made their response on 17 November 2019.
  2. 2

    Publish information about the Trust’s Triangle of Care work on its webpage.

    Stated by West London NHS TrustStated completedThe respondent said that this action was complete when they made their response on 17 November 2019.
  3. 3

    Complete Triangle of Care Stage One self-assessments across inpatient and crisis teams.

    Stated by West London NHS TrustStated completedThe respondent said that this action was complete when they made their response on 17 November 2019.
  4. 4

    Strengthen measurement of the impact of carer and family involvement work.

    Stated by West London NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 17 November 2019.
  5. 5

    Ensure all staff attend Carer Awareness Training.

    Stated by West London NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 17 November 2019.
  6. 6

    Take steps to establish a Carers Council.

    Stated by West London NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 17 November 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

Maintain a Triangle of Care project delivery plan and risk log, with regular updates reported through Trust governance meetings.

Verbatim wording from the response

“22. To support implementation of the ‘Triangle of Care’ across the Trust, an overarching project delivery plan and risk log has been developed. This has been presented to the Trust Board. Regular project delivery updates are reported to the Trust Service User and Carer Experience meeting, and from there, to the Trust Board.”

Source location

2019-0349-Response-from-West-London-NHS-Trust-Redacted
Page 4 · response
Published 17 November 2019

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 information about the Trust’s Triangle of Care work on its webpage.

Verbatim wording from the response

“25. Further details about the work we are doing is available on our ‘Triangle of Care’ webpage, which can be found by following the link:”

Source location

2019-0349-Response-from-West-London-NHS-Trust-Redacted
Page 4 · response
Published 17 November 2019

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 Triangle of Care Stage One self-assessments across inpatient and crisis teams.

Verbatim wording from the response

“21. The Trust is a formal member of the ‘Triangle of Care’ membership scheme, and we have committed to implementing the standards set out in the ‘Triangle of Care’. Part of this includes submitting regular progress reports to the Carers Trust. Progress reports for each stage of implementing the ‘Triangle of Care’ (Stage 1 and Stage 2) are expected. At West London NHS Trust, ‘Stage 1’ is the roll out of self-assessments throughout our inpatient services and crisis teams, and ‘Stage 2’ is the roll out of self-assessments throughout community services. We are currently considering whether a further stage is required for our community physical health services.”

Source location

2019-0349-Response-from-West-London-NHS-Trust-Redacted
Page 4 · response
Published 17 November 2019

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 measurement of the impact of carer and family involvement work.

Verbatim wording from the response

“• To strengthen how we measure the impact of the work we do”

Source location

2019-0349-Response-from-West-London-NHS-Trust-Redacted
Page 4 · response
Published 17 November 2019

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

Ensure all staff attend Carer Awareness Training.

Verbatim wording from the response

“• To focus on the expectation that all staff attend Carer Awareness Training”

Source location

2019-0349-Response-from-West-London-NHS-Trust-Redacted
Page 4 · response
Published 17 November 2019

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

Take steps to establish a Carers Council.

Verbatim wording from the response

“• To take steps to establish a Carers Council”

Source location

2019-0349-Response-from-West-London-NHS-Trust-Redacted
Page 4 · response
Published 17 November 2019

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