PFD report

Natasha Elizabeth Victoria Abrahart · Prevention of Future Deaths report

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Issued 16 May 2019•Avon

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
3

Named on the report

Responses found
3

Of 3 recipients

Stated actions
14

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 arrange timely follow-up review after starting antidepressants for people at increased suicide risk or younger than 30 years
    Part of recurring concern: Failure to provide timely clinical follow-up after medication prescribingPart of recurring concern: Failure to provide timely continuing mental health reviews and follow-upPart of recurring concern: Failure to reliably follow up identified mental-health safety concerns
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.5

  1. Action

    Schedule routine reviews one week after starting an SSRI, with booked or known follow-up appointments and appropriate follow-up after cancellations or non-attendance.

    Stated by University of Bristol Students’ Health ServiceStated completedThe respondent said that this action was complete when they made their response on 14 May 2020.
  2. Action

    Recruit a permanent mental health nurse, define a role reviewing higher-risk or SSRI-starting patients at seven days, and plan use of the new resource with local partners.

    Stated by University of Bristol Students’ Health ServiceStated in progressThe respondent said that this action was in progress when they made their response on 14 May 2020.
  3. Action

    Add an SSRI and suicidality prompt to the first mental health assessment template.

    Stated by University of Bristol Students’ Health ServiceStated completedThe respondent said that this action was complete when they made their response on 14 May 2020.

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

  1. Position

    Changing QOF depression review criteria requires national-level action, with feedback routed through the local CCG.

    Stated by University of Bristol Students’ Health ServiceRedirects 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

Failure to arrange timely follow-up review after starting antidepressants for people at increased suicide risk or younger than 30 years

Wider context from the report

“The NICE guideline Depression in Adults: Recognition and management (CG90) states in section 1.5.2.7 “A person with depression started on antidepressants who is considered to present an increased suicide risk or is younger than 30 years (because of the potential increased prevalence of suicidal thoughts in the early stages of antidepressant treatment for this group) should normally be seen after 1 week and frequently thereafter as appropriate until the risk is no longer considered clinically important” In this case Sertraline was prescribed but the NICE guideline was not followed by the mental health trust or the GP practice. The expert indicated that the review at 1 week is to ensure that the patient is taking the medication, to check for any side effects including suicide risk and to see what has happened; that review can be done by the G.P. or the mental health team but there needs to be a known appointment. ”

Is this part of a recurring concern?

Yes — Failure to provide timely clinical follow-up after medication prescribing; Failure to provide timely continuing mental health reviews and follow-up; Failure to reliably follow up identified mental-health safety concerns.

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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

Schedule routine reviews one week after starting an SSRI, with booked or known follow-up appointments and appropriate follow-up after cancellations or non-attendance.

Verbatim wording from the response

“In response to the concerns expressed within your Regulation 28 report, we have moved appointments to review patients when starting an SSRI routinely to 1 week, if this is manageable for the patient, and have this as a ‘booked’ or ‘known’ appointment in accordance with NICE guidance.”

Source location

2019-0504-Response-from-University-of-Bristol_Redacted
Page 4 · response
Published 14 May 2020

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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

Recruit a permanent mental health nurse, define a role reviewing higher-risk or SSRI-starting patients at seven days, and plan use of the new resource with local partners.

Verbatim wording from the response

“Since the inquest we have requested additional funding from the University to advertise for a permanent Mental Health Nurse to join our team and this has been agreed. We are currently working on an advert and job description. The job plan for this member of the team would include reviewing patients under 30 thought to be at risk of suicide, or starting on SSRI, at 7 days. We are liaising with local partners, mental health advisory service and psychology team to plan how best to utilise this new resource.”

Source location

2019-0504-Response-from-University-of-Bristol_Redacted
Page 4 · response
Published 14 May 2020

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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

Add an SSRI and suicidality prompt to the first mental health assessment template.

Verbatim wording from the response

“Following the inquest touching upon NA’s death, we have added an additional field on our first mental health assessment template regarding SSRI and suicidality: “If SSRI newly prescribed: counsel re side effects and risk increase suicidality; when is follow up?””

Source location

2019-0504-Response-from-University-of-Bristol_Redacted
Page 4 · response
Published 14 May 2020

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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

Require medical leads to discuss the prescribing alert with all line reports to reinforce effective communication.

Verbatim wording from the response

“We have distributed a Red Top Alert via our Trust-wide alerting system instructing all medical personnel, all non-medical prescribers, all pharmacists and all team managers to be ensure that prescribers follow the NICE Guidance in relation to the prescribing of anti-depressants (CG90). The instruction includes a requirement to adhere to the guidance and makes clear the responsibility to communicate effectively with primary care about which individual will undertake the review at seven days; and that this must be clearly documented. There is a robust auditable system which demands a response from all the teams circulated in the alert, permitting the identification of any gaps. There will be an obligation for medical leads to discuss this with all their line reports, to ensure effective communication of this alert.”

Source location

2019-0504-Response-from-AWP
Page 1 · response
Published 14 May 2020

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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

Distribute a Trust-wide alert requiring adherence to NICE antidepressant-prescribing guidance, documented seven-day review responsibility, and auditable team responses.

Verbatim wording from the response

“We have distributed a Red Top Alert via our Trust-wide alerting system instructing all medical personnel, all non-medical prescribers, all pharmacists and all team managers to be ensure that prescribers follow the NICE Guidance in relation to the prescribing of anti-depressants (CG90). The instruction includes a requirement to adhere to the guidance and makes clear the responsibility to communicate effectively with primary care about which individual will undertake the review at seven days; and that this must be clearly documented. There is a robust auditable system which demands a response from all the teams circulated in the alert, permitting the identification of any gaps. There will be an obligation for medical leads to discuss this with all their line reports, to ensure effective communication of this alert.”

Source location

2019-0504-Response-from-AWP
Page 1 · response
Published 14 May 2020

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

Changing QOF depression review criteria requires national-level action, with feedback routed through the local CCG.

Verbatim wording from the response

“The current QOF (Quality Outcomes Framework) for depression states that a depression interim review should be undertaken at 10-56 days. Having reviewed the guidance around treatment of depression we would suggest that changing the achievement criteria within this QOF domain is a potential area for positive change. A change to this time frame might improve mental health outcomes across primary care, if it were updated at national level to reflect best practice. We intend to feed this back to our local CCG in the near future.”

Source location

2019-0504-Response-from-University-of-Bristol_Redacted
Page 3 · response
Published 14 May 2020

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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.9

  1. 1

    Feed back to the local CCG the potential need to change national depression QOF review timeframes.

    Stated by University of Bristol Students’ Health ServiceStated plannedThe respondent said that this action was planned when they made their response on 14 May 2020.
  2. 2

    Continue monitoring practice systems to ensure care remains consistent with NICE and local guidelines.

    Stated by University of Bristol Students’ Health ServiceStated completedThe respondent said that this action was complete when they made their response on 14 May 2020.
  3. 3

    Share learning from the death through scheduled Medical Leads, Trust-wide Medical Advisory, Learning from Experiences, and Medicines Optimisation meetings.

    Stated by Avon and Wiltshire Mental Health Partnership NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 14 May 2020.
  4. 4

    Publish the cross-Government Suicide Prevention Workplan.

    Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 14 May 2020.
  5. 5

    Fund 10 projects developing new approaches to student mental health, including partnerships with primary care and mental health services.

    Stated by Department of Health and Social CareStated in progressThe respondent said that this action was in progress when they made their response on 14 May 2020.
  6. 6

    Publish guidance for universities on measures to help prevent student suicide.

    Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 14 May 2020.
  7. 7

    Communicate the funded projects’ outcomes across the higher education sector.

    Stated by Department of Health and Social CareStated plannedThe respondent said that this action was planned when they made their response on 14 May 2020.
  8. 8

    Support the University Mental Health Charter to improve standards for student and staff mental health and wellbeing.

    Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 14 May 2020.
  9. 9

    Announce £1 million of additional funding for health and education partnership proposals.

    Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 14 May 2020.

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

Feed back to the local CCG the potential need to change national depression QOF review timeframes.

Verbatim wording from the response

“The current QOF (Quality Outcomes Framework) for depression states that a depression interim review should be undertaken at 10-56 days. Having reviewed the guidance around treatment of depression we would suggest that changing the achievement criteria within this QOF domain is a potential area for positive change. A change to this time frame might improve mental health outcomes across primary care, if it were updated at national level to reflect best practice. We intend to feed this back to our local CCG in the near future.”

Source location

2019-0504-Response-from-University-of-Bristol_Redacted
Page 3 · response
Published 14 May 2020

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

Continue monitoring practice systems to ensure care remains consistent with NICE and local guidelines.

Verbatim wording from the response

“As a practice we are committed to adhering to best practice wherever possible, and to ensuring that our procedures are compliant with NICE and local guidelines. The inquest touching Natasha’s death has afforded us an opportunity to review systems in place alongside the relevant guidance. We are confident that the changes described above are consistent with local and national guidance. In future we will continue to monitor our systems at the practice to ensure we are providing care to our patients in accordance with these guidelines.”

Source location

2019-0504-Response-from-University-of-Bristol_Redacted
Page 4 · response
Published 14 May 2020

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

Share learning from the death through scheduled Medical Leads, Trust-wide Medical Advisory, Learning from Experiences, and Medicines Optimisation meetings.

Verbatim wording from the response

“In addition to the alert, this will also be raised at various fora across the Trust, ensuring that the learning from this tragic death is shared as widely and comprehensively as possible. These include:”

Source location

2019-0504-Response-from-AWP
Page 1 · response
Published 14 May 2020

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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

Publish the cross-Government Suicide Prevention Workplan.

Verbatim wording from the response

“This Government has set out an ambitious programme of work to reduce suicides, including actions being taken to improve the mental health of university students. This ambition is set out in the first cross-Government Suicide Prevention Workplan published in January 2019³.”

Source location

2019-0504-Response-from-the-Department-for-Health-and-Social-Care
Page 3 · response
Published 14 May 2020

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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

Fund 10 projects developing new approaches to student mental health, including partnerships with primary care and mental health services.

Verbatim wording from the response

“• Funding investment in 10 projects encouraging higher education providers to find new ways of combating student mental health issues, including the development of links between higher education providers and local primary care and mental health services⁵. Outcomes will be widely communicated across the sector;”

Source location

2019-0504-Response-from-the-Department-for-Health-and-Social-Care
Page 3 · response
Published 14 May 2020

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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

Publish guidance for universities on measures to help prevent student suicide.

Verbatim wording from the response

“• Guidance on measures to help prevent suicide, ‘Suicide-Safer Universities’⁴, 2018. All universities are expected to actively engage with the guidance to improve mental health support and reduce suicide risks amongst their student population;”

Source location

2019-0504-Response-from-the-Department-for-Health-and-Social-Care
Page 3 · response
Published 14 May 2020

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

Communicate the funded projects’ outcomes across the higher education sector.

Verbatim wording from the response

“• Funding investment in 10 projects encouraging higher education providers to find new ways of combating student mental health issues, including the development of links between higher education providers and local primary care and mental health services⁵. Outcomes will be widely communicated across the sector;”

Source location

2019-0504-Response-from-the-Department-for-Health-and-Social-Care
Page 3 · response
Published 14 May 2020

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

Support the University Mental Health Charter to improve standards for student and staff mental health and wellbeing.

Verbatim wording from the response

“• The University Mental Health Charter⁷, supported by the Government and led by the higher education sector to drive up standards in promoting student and staff mental health and wellbeing; and,”

Source location

2019-0504-Response-from-the-Department-for-Health-and-Social-Care
Page 3 · response
Published 14 May 2020

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

Announce £1 million of additional funding for health and education partnership proposals.

Verbatim wording from the response

“• £1 million extra funding announced by the Prime Minister in June 2019 for proposals to promote partnership working between the health and education sectors⁶;”

Source location

2019-0504-Response-from-the-Department-for-Health-and-Social-Care
Page 3 · response
Published 14 May 2020

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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