PFD report

ANDREW STUART CODLING · Prevention of Future Deaths report

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Issued 23 Jun 2017•Bedfordshire and Luton

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
1

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
2

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. Failure to communicate the availability of alternative support before Monday morning
    Part of recurring concern: Failure to ensure care staff can communicate effectively with residents and patients
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

    Provide service users with an explanatory letter, including alternative contact arrangements, whenever staff give them a mobile-phone number.

    Stated by East London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 18 December 2017.
  2. Action

    Develop and implement a CMHT protocol governing mobile-phone communication and requiring staff to provide urgent-support contacts when service users do not answer calls.

    Stated by East London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 18 December 2017.

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

  1. Position

    The Trust considers that its action adequately addresses the concern and that no further safety work is necessary.

    Stated by East London NHS Foundation TrustNo action considered necessaryThe respondent said that 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

Failure to communicate the availability of alternative support before Monday morning

Wider context from the report

“(3) That call missed the opportunity to re-inforce the fact that there were other means of help should the deceased require it, including the crisis numbers already provided by the Service. (4) Reminding the deceased that there was provision to provide support before Monday morning may have been all the deceased required to avoid taking the decision to hang himself particularly, bearing in mind it was the deceased who had initiated the call ”

Is this part of a recurring concern?

Yes — Failure to ensure care staff can communicate effectively with residents and patients.

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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

Provide service users with an explanatory letter, including alternative contact arrangements, whenever staff give them a mobile-phone number.

Verbatim wording from the response

“In response to the concerns raised, a new protocol has been developed and implemented within the CMHTs. The protocol provides guidance to staff in relation to the use of mobile phones in communication with service users. Where a member of staff provides a service user with their mobile phone number an explanatory letter is now provided. This includes information on who can be contacted should the call not be answered, depending on the nature of the call and what assistance is required.”

Source location

2017-0339-Response-by-East-London-NHS-Trust
Page 1 · response
Published 18 December 2017

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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 implement a CMHT protocol governing mobile-phone communication and requiring staff to provide urgent-support contacts when service users do not answer calls.

Verbatim wording from the response

“In response to the concerns raised, a new protocol has been developed and implemented within the CMHTs. The protocol provides guidance to staff in relation to the use of mobile phones in communication with service users. Where a member of staff provides a service user with their mobile phone number an explanatory letter is now provided. This includes information on who can be contacted should the call not be answered, depending on the nature of the call and what assistance is required.”

Source location

2017-0339-Response-by-East-London-NHS-Trust
Page 1 · response
Published 18 December 2017

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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 Trust considers that its action adequately addresses the concern and that no further safety work is necessary.

Verbatim wording from the response

“I hope that the action taken provides you with assurance that the Trust has taken appropriate action and that your concern has been adequately addressed.”

Source location

2017-0339-Response-by-East-London-NHS-Trust
Page 2 · response
Published 18 December 2017

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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