PFD report

Shaun Kenny HALL · Prevention of Future Deaths report

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Issued 30 Jan 2025•Northamptonshire

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
5

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 to record referrals
  2. Failure to identify the person declining a referral
    Part of recurring concern: Unreliable mental health referral pathways
  3. Failure to accept a referral despite available information indicating escalating suicide risk
    Part of recurring concern: Unreliable urgent mental health referral and assessment pathways
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 new risk management processes, including policy updates and revised risk documentation, for UCAT and crisis and community services.

    Stated by Northamptonshire Healthcare NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 31 January 2025.
  2. Action

    Enable UCAT and Talking Therapies staff to access full records for service users in their care.

    Stated by Northamptonshire Healthcare NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 31 January 2025.
  3. Action

    Extend web-based call handling and recording systems to UCAT services and train staff to use them.

    Stated by Northamptonshire Healthcare NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 31 January 2025.

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 record referrals

Wider context from the report

“The assessment from Talking Therapies on 20 November 2023 identified current escalating factors around not being allowed to see his children, and an upcoming court case in relation to this on 14 December 2023. Indeed he stated that if he was not allowed to see his children he would take his own life. Despite all this information being available the Urgent Care and Assessment Team did not accept the referral. Of grave concern is that the identity of the person at the Urgent Care and Assessment Team who declined the referral is not known and no notes were made of the referral. ”

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

Failure to identify the person declining a referral

Wider context from the report

“The assessment from Talking Therapies on 20 November 2023 identified current escalating factors around not being allowed to see his children, and an upcoming court case in relation to this on 14 December 2023. Indeed he stated that if he was not allowed to see his children he would take his own life. Despite all this information being available the Urgent Care and Assessment Team did not accept the referral. Of grave concern is that the identity of the person at the Urgent Care and Assessment Team who declined the referral is not known and no notes were made of the referral. ”

Is this part of a recurring concern?

Yes — Unreliable mental health referral pathways.

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 accept a referral despite available information indicating escalating suicide risk

Wider context from the report

“The assessment from Talking Therapies on 20 November 2023 identified current escalating factors around not being allowed to see his children, and an upcoming court case in relation to this on 14 December 2023. Indeed he stated that if he was not allowed to see his children he would take his own life. Despite all this information being available the Urgent Care and Assessment Team did not accept the referral. Of grave concern is that the identity of the person at the Urgent Care and Assessment Team who declined the referral is not known and no notes were made of the referral. ”

Is this part of a recurring concern?

Yes — Unreliable urgent mental health referral and assessment pathways.

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

Develop new risk management processes, including policy updates and revised risk documentation, for UCAT and crisis and community services.

Verbatim wording from the response

“In response to several national drivers and as part of our Trust’s commitment to continuous improvement and learning from incidents, we are developing a range of new risk management processes, including policy updates, changes to risk management documentation and the commissioning of new training modules.”

Source location

Response from Northamptonshire Healthcare Foundation Trust
Page 1 · response
Published 31 January 2025

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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

Enable UCAT and Talking Therapies staff to access full records for service users in their care.

Verbatim wording from the response

“Having further examined the circumstances surrounding Mr Hall’s death, we have understood the need for a greater level of patient records visibility between UCAT and Talking Therapies staff. We have now enabled both UCAT and Talking Therapies staff to have full visibility of all records relating to the treatment of service users in their care.”

Source location

Response from Northamptonshire Healthcare Foundation Trust
Page 3 · response
Published 31 January 2025

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

Extend web-based call handling and recording systems to UCAT services and train staff to use them.

Verbatim wording from the response

“We have heard the concerns you raised and have elected to expand the use of call handling and recording systems within the Trust to our Crisis Services. We currently use a web-based call handling product within our response hub and have begun the process of extending the product into the UCAT services. By the end of July 2025, we anticipate that we will have trained all staff in the use of this product. This product will improve the accuracy of our record keeping and our ability to provide reflective interventions with staff.”

Source location

Response from Northamptonshire Healthcare Foundation Trust
Page 2 · response
Published 31 January 2025

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

Develop a record-keeping audit tool to govern the quality and content of clinical records.

Verbatim wording from the response

“We expect all clinical staff to adhere to the record keeping standards of their respective professional body and to comply with our ‘Health Records Management and Keeping Standards Policy’. We emphasised the importance of record keeping at the time of the incident to all staff in the UCAT team as a result of our initial learning. We continue to track the team’s compliance with mandatory information governance training and have developed a new record keeping audit tool that ensures governance over the quality and content of records.”

Source location

Response from Northamptonshire Healthcare Foundation Trust
Page 2 · response
Published 31 January 2025

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.1

  1. 1

    Roll out externally commissioned training on risk formulation and safety planning across community teams.

    Stated by Northamptonshire Healthcare NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 31 January 2025.

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

Roll out externally commissioned training on risk formulation and safety planning across community teams.

Verbatim wording from the response

“To support the transition to our new approach to risk formulation, we commissioned a training module from a leading, external provider that brings in national best practice and core skills around formulation and safety planning. To date we have trained more than 140 of our community staff and continue to roll this out across our teams. This represents 80% of the community workforce at this time.”

Source location

Response from Northamptonshire Healthcare Foundation Trust
Page 2 · response
Published 31 January 2025

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