PFD report

Uyapo Theodore Hayunga-Macha · Prevention of Future Deaths report

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Issued 20 Sep 2021•Liverpool and the Wirral

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
2

Of 3 recipients

Stated actions
10

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 provide care and supervision while awaiting assessment
    Part of recurring concern: Inadequate supervision of patients in acute hospital assessment areasPart of recurring concern: Unreliable interim mental health support during care transitions
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

    Complete online mental-health training for clinical support workers caring for patients in the Mental Health Unit.

    Stated by Wirral University Teaching Hospital NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 23 September 2021.
  2. Action

    Take forward further staff education and training on caring for mental-health patients and appropriate use of the Mental Health Unit.

    Stated by Wirral University Teaching Hospital NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 23 September 2021.
  3. Action

    Triage all ambulance-service arrivals on entry, document fit-to-sit rationales, and require verbal handover to the appropriate assessment or triage nurse.

    Stated by Wirral University Teaching Hospital NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 23 September 2021.

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 provide care and supervision while awaiting assessment

Wider context from the report

“On 3 December 2020 Merseyside Police were called to Theo where it was apparent that he was suffering from poor mental health. An ambulance was called and Theo agreed to be taken to Arrowe Park Hospital. It is reported that whilst waiting for Triage that he left without being seen. Why was he not being looked after? And why was he left alone when waiting for assessment? ”

Is this part of a recurring concern?

Yes — Inadequate supervision of patients in acute hospital assessment areas; Unreliable interim mental health support during care transitions.

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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

Complete online mental-health training for clinical support workers caring for patients in the Mental Health Unit.

Verbatim wording from the response

“2. Further education and training for staff in relation to dealing with Mental Health patients and appropriate use of the Mental Health Unit (MHU). The Clinical support Workers who provide care and support for patients within the MHU have completed an online Mental Health training session”

Source location

2021-0314-Response-from-Wirral-University-Teaching-Hospital_Published
Page 1 · response
Published 23 September 2021

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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

Take forward further staff education and training on caring for mental-health patients and appropriate use of the Mental Health Unit.

Verbatim wording from the response

“2. Further education and training for staff in relation to dealing with Mental Health patients and appropriate use of the Mental Health Unit (MHU). The Clinical support Workers who provide care and support for patients within the MHU have completed an online Mental Health training session”

Source location

2021-0314-Response-from-Wirral-University-Teaching-Hospital_Published
Page 1 · response
Published 23 September 2021

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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

Triage all ambulance-service arrivals on entry, document fit-to-sit rationales, and require verbal handover to the appropriate assessment or triage nurse.

Verbatim wording from the response

“4. Ensure a standardised handover process to alert initial assessment / triage staff when a patient is placed in the waiting room as “fit to sit” by Ambulance Triage Nurse (ATN). All patients who arrive under the care of the North West Ambulance Service are now triaged by the ATN. This is a change in practice; previously, if patients were directed to the waiting room on arrival, as considered “fit to sit”, they would have been booked by the administrative team, at the main reception and would have waited to undergo initial triage assessment. The ATN now completes a triage assessment on arrival for all patients, including those presenting with a mental health concern. If this assessment finds the patient able to sit in the waiting room, the rationale for this decision is documented.”

Source location

2021-0314-Response-from-Wirral-University-Teaching-Hospital_Published
Page 2 · response
Published 23 September 2021

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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

Escalate full Mental Health Unit capacity to the Tactical Commander and shift leader, with defined overnight senior-doctor and shift-leader decision-making, and communicate the process to staff.

Verbatim wording from the response

“Unfortunately there are times when our MHU is full. A process has been developed to ensure that this is escalated to the Tactical Commander (TC) and the Shift leader, who are then responsible for decisions regarding either stepping someone out of MHU to create space, or where to place patients who are just arriving. Overnight if the TC is not on site, the decision is made by the senior Dr and Shift Leader. This process has been communicated to all staff.”

Source location

2021-0314-Response-from-Wirral-University-Teaching-Hospital_Published
Page 2 · response
Published 23 September 2021

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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

Conduct monthly audits of 50 ambulance-service patients and share assessment, observation and triage findings with the Patient Safety and Quality Board.

Verbatim wording from the response

“The Emergency Department leadership team have arranged for an audit of 50 patients per month to be undertaken to provide ongoing assurance around assessment/observations and triage of patients, who arrive via the ambulance service, the results of which are shared at the Trust’s Patient Safety and Quality Board.”

Source location

2021-0314-Response-from-Wirral-University-Teaching-Hospital_Published
Page 2 · response
Published 23 September 2021

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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.5

  1. 1

    Raise ED staff awareness of the missing-patient protocol through safety huddles and incorporate the policy and documentation into new-staff induction.

    Stated by Wirral University Teaching Hospital NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 23 September 2021.
  2. 2

    Improve communication between onsite security and the Emergency Department when police make missing-person enquiries.

    Stated by Wirral University Teaching Hospital NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 23 September 2021.
  3. 3

    Establish a Mental Health Transformation Group led by the Interim Chief Nurse to coordinate partnership work on mental-health care.

    Stated by Wirral University Teaching Hospital NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 23 September 2021.
  4. 4

    Advance identified mental-health focus workstreams covering strategy, escalation, capacity training, paediatric processes, de-escalation training, and service-need monitoring.

    Stated by Wirral University Teaching Hospital NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 23 September 2021.
  5. 5

    Continue partnership work through the Mental Health Transformation Group to improve emergency-department care, covering escalation, training, paediatric processes, Mental Health Act provision, and service planning.

    Stated by Cheshire and Wirral Partnership NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 23 September 2021.

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

Raise ED staff awareness of the missing-patient protocol through safety huddles and incorporate the policy and documentation into new-staff induction.

Verbatim wording from the response

“1. Ensure the ED Team are aware of the missing patient protocol and when it needs to be used. The Lead Nurse for the ED has raised awareness with staff, within the department, through a series of discussions at the department’s safety huddles. In addition the missing patient policy and documentation has been incorporated into the new staff induction programme. These actions were completed in June 2021.”

Source location

2021-0314-Response-from-Wirral-University-Teaching-Hospital_Published
Page 1 · response
Published 23 September 2021

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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

Improve communication between onsite security and the Emergency Department when police make missing-person enquiries.

Verbatim wording from the response

“3. Improved communication between ED and security regarding police enquiries. Discussions have been undertaken to ensure that when the Trust’s onsite security are contacted by the Police regarding a Missing person, there is communication with the Emergency Department.”

Source location

2021-0314-Response-from-Wirral-University-Teaching-Hospital_Published
Page 2 · response
Published 23 September 2021

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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

Establish a Mental Health Transformation Group led by the Interim Chief Nurse to coordinate partnership work on mental-health care.

Verbatim wording from the response

“I would also like to make you aware of a broader piece of work currently underway within the Trust relating to the care of patients with mental health illness. You will be aware of the impact of the current pandemic on the populations mental health and the associated increasing demand for services. In response we have established a Mental Health Transformation Group which is currently being led by the Interim Chief Nurse. This Group has identified the following areas for further focus work:”

Source location

2021-0314-Response-from-Wirral-University-Teaching-Hospital_Published
Page 2 · response
Published 23 September 2021

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

Advance identified mental-health focus workstreams covering strategy, escalation, capacity training, paediatric processes, de-escalation training, and service-need monitoring.

Verbatim wording from the response

“I would also like to make you aware of a broader piece of work currently underway within the Trust relating to the care of patients with mental health illness. You will be aware of the impact of the current pandemic on the populations mental health and the associated increasing demand for services. In response we have established a Mental Health Transformation Group which is currently being led by the Interim Chief Nurse. This Group has identified the following areas for further focus work:”

Source location

2021-0314-Response-from-Wirral-University-Teaching-Hospital_Published
Page 2 · response
Published 23 September 2021

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 partnership work through the Mental Health Transformation Group to improve emergency-department care, covering escalation, training, paediatric processes, Mental Health Act provision, and service planning.

Verbatim wording from the response

“I would like to provide assurance that the Trust is actively involved in a broader piece of work with Wirral University Teaching Hospital (WUHT) relating to the care of patients with mental health illness. The Trust is involved in the Mental Health Transformation Group which is currently being led by the Interim Chief Nurse at WUTH. This Group has identified the following areas for further focused work:”

Source location

2021-0314-Response-from-Cheshire-and-Wirral-Partnership_Published
Page 2 · response
Published 23 September 2021

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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