PFD report

Roy Keith MORRIS · Prevention of Future Deaths report

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Issued 29 Mar 2021•Buckinghamshire

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
2

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
15

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 raised2

  1. Failure to provide detailed CPA care plans that inform patients, families, care coordinators and community teams on discharge
    Part of recurring concern: Unreliable hospital discharge processes
  2. Delays in allocating care coordinators to inpatients shortly after admission
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

    Appoint a patient flow manager to support care coordinator allocation and resolution of discharge-planning barriers.

    Stated by Oxford Health NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 13 April 2021.
  2. Action

    Review care coordinator allocation structures, processes and role expectations within community mental health teams.

    Stated by Oxford Health NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 13 April 2021.
  3. Action

    Create a task and finish group of relevant clinicians to strengthen application of CPA policy and care coordinator practice.

    Stated by Oxford Health NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 13 April 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 detailed CPA care plans that inform patients, families, care coordinators and community teams on discharge

Wider context from the report

“1. The application of the CPA policy for patients such as Roy so that they will have a detailed care plan with which they can engage and which informs the family, the care coordinator and the community team on discharge from the inpatient setting. ”

Is this part of a recurring concern?

Yes — Unreliable hospital discharge processes.

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

Delays in allocating care coordinators to inpatients shortly after admission

Wider context from the report

“2. Reinforcing the importance of the role of care coordinator and ensuring the timely allocation to inpatients shortly after admission so that they can work over a meaningful period with the patient, the family and the mental health teams in anticipation of the discharge into the community. ”

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

Appoint a patient flow manager to support care coordinator allocation and resolution of discharge-planning barriers.

Verbatim wording from the response

“This will involve discussion at each ward’s rapid reviews (which are held three times per week on each of the acute wards) and escalations at our twice daily teleconferences (chaired by senior nurses and service managers) for our inpatient and our community teams. This work will be supported through the newly appointed patient flow manager and will strengthen the daily action log from the bed escalation meetings to quickly identify and resolve with service managers any barriers to completing the allocation of care coordinators. The revised bed meetings and escalations calls will ensure that we are allocating care coordinators at the earliest opportunity to support engagement in discharge planning.”

Source location

2021-0094-Response-from-Littlemore-Mental-Health-Centre-Redacted
Page 2 · response
Published 13 April 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

Review care coordinator allocation structures, processes and role expectations within community mental health teams.

Verbatim wording from the response

“- To review the standard operating policies for our community mental health teams to reflect the standards of practice expected in the role of care coordinator, which is pivotal to the delivery of care. - To review the induction process and package for both permanent and locum staff, with an aide memoire for both existing staff and new and locum staff to familiarise themselves with the role and expected standard of practice for the role and their team’s structure and processes. - To review the structure and process of care coordinator allocation within mental health community teams and the expectations of the role in order to ensure adherence of the Trust CPA policy. - To review the daily bed management and escalations meetings to capture care co-ordinator allocation and clear communication between the mental health community teams and inpatient teams.”

Source location

2021-0094-Response-from-Littlemore-Mental-Health-Centre-Redacted
Page 2 · response
Published 13 April 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

Create a task and finish group of relevant clinicians to strengthen application of CPA policy and care coordinator practice.

Verbatim wording from the response

“I will state immediately that as an organisation we understand and accept the concerns that you have raised. As stated in your report, our CPA policy stipulates the requirement of a detailed care plan and recommends that the individual (or patient) and their family are involved in designing the plan of care and support required to ensure a timely and smooth discharge from hospital. We have therefore sought to strengthen the understanding and application of our policy within our teams by creating a task and finish group with relevant clinicians. The group’s main functions will be as follows:”

Source location

2021-0094-Response-from-Littlemore-Mental-Health-Centre-Redacted
Page 1 · response
Published 13 April 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

Strengthen the bed-escalation action log and use rapid reviews and escalation calls to identify and resolve barriers to timely care coordinator allocation.

Verbatim wording from the response

“This will involve discussion at each ward’s rapid reviews (which are held three times per week on each of the acute wards) and escalations at our twice daily teleconferences (chaired by senior nurses and service managers) for our inpatient and our community teams. This work will be supported through the newly appointed patient flow manager and will strengthen the daily action log from the bed escalation meetings to quickly identify and resolve with service managers any barriers to completing the allocation of care coordinators. The revised bed meetings and escalations calls will ensure that we are allocating care coordinators at the earliest opportunity to support engagement in discharge planning.”

Source location

2021-0094-Response-from-Littlemore-Mental-Health-Centre-Redacted
Page 2 · response
Published 13 April 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

Review bed-management and escalation meetings to capture care coordinator allocation and communication between inpatient and community teams.

Verbatim wording from the response

“- To review the standard operating policies for our community mental health teams to reflect the standards of practice expected in the role of care coordinator, which is pivotal to the delivery of care. - To review the induction process and package for both permanent and locum staff, with an aide memoire for both existing staff and new and locum staff to familiarise themselves with the role and expected standard of practice for the role and their team’s structure and processes. - To review the structure and process of care coordinator allocation within mental health community teams and the expectations of the role in order to ensure adherence of the Trust CPA policy. - To review the daily bed management and escalations meetings to capture care co-ordinator allocation and clear communication between the mental health community teams and inpatient teams.”

Source location

2021-0094-Response-from-Littlemore-Mental-Health-Centre-Redacted
Page 2 · response
Published 13 April 2021

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.10

  1. 1

    Identify carers through Better Lives and carers’ assessments and audit admission checklists to monitor adherence.

    Stated by Oxford Health NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 13 April 2021.
  2. 2

    Deliver workshops and road shows for community teams to disseminate revised care coordination procedures and guidelines.

    Stated by Oxford Health NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 13 April 2021.
  3. 3

    Review induction materials and create aide-memoires explaining care coordinator roles, team structures and processes for existing, permanent, locum and new staff.

    Stated by Oxford Health NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 13 April 2021.
  4. 4

    Roll out carers-awareness training within Trust teams.

    Stated by Oxford Health NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 13 April 2021.
  5. 5

    Carry out directorate quality-improvement work on working with families to improve engagement and embed the Triangle of Care.

    Stated by Oxford Health NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 13 April 2021.
  6. 6

    Review and relaunch the Trust carers’ strategy.

    Stated by Oxford Health NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 13 April 2021.
  7. 7

    Offer carers ward-based introductions and one-to-one time with carer link nurses and primary nurses within 72 hours of admission.

    Stated by Oxford Health NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 13 April 2021.
  8. 8

    Maintain defined carer link worker roles responsible for supporting carers within Trust teams.

    Stated by Oxford Health NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 13 April 2021.
  9. 9

    Review community mental health team operating procedures to reflect expected care coordinator standards.

    Stated by Oxford Health NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 13 April 2021.
  10. 10

    Maintain confidentiality and information-sharing policies and protocols for carers within Trust teams.

    Stated by Oxford Health NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 13 April 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

Identify carers through Better Lives and carers’ assessments and audit admission checklists to monitor adherence.

Verbatim wording from the response

“- Carers and the essential role they play should be identified at first contact with services or as soon as possible thereafter: we are using better lives assessments and carers’ assessments to identify who are carers and how best to work with them, as well as using our admission check lists audits to ensure standards are adhered to.”

Source location

2021-0094-Response-from-Littlemore-Mental-Health-Centre-Redacted
Page 2 · response
Published 13 April 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

Deliver workshops and road shows for community teams to disseminate revised care coordination procedures and guidelines.

Verbatim wording from the response

“Once the Standard Operating Procedure for Community Mental Health Teams has been finalised, with easy-to-follow guidelines as aide memoires, the Head of Service and Head of Nursing will jointly deliver a series of workshops and road shows with all community teams to disseminate the updated and focused material to support the required consistency in approach to care coordination. The workshops will commence in early June 2021.”

Source location

2021-0094-Response-from-Littlemore-Mental-Health-Centre-Redacted
Page 2 · response
Published 13 April 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

Review induction materials and create aide-memoires explaining care coordinator roles, team structures and processes for existing, permanent, locum and new staff.

Verbatim wording from the response

“- To review the standard operating policies for our community mental health teams to reflect the standards of practice expected in the role of care coordinator, which is pivotal to the delivery of care. - To review the induction process and package for both permanent and locum staff, with an aide memoire for both existing staff and new and locum staff to familiarise themselves with the role and expected standard of practice for the role and their team’s structure and processes. - To review the structure and process of care coordinator allocation within mental health community teams and the expectations of the role in order to ensure adherence of the Trust CPA policy. - To review the daily bed management and escalations meetings to capture care co-ordinator allocation and clear communication between the mental health community teams and inpatient teams.”

Source location

2021-0094-Response-from-Littlemore-Mental-Health-Centre-Redacted
Page 2 · response
Published 13 April 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

Roll out carers-awareness training within Trust teams.

Verbatim wording from the response

“- Staff should be aware of carers and trained to engage with carers more effectively. The Trust has reviewed and re-launched the Trust’s carers’ strategy. Carers awareness training forms part of the carers’ strategy being rolled out within our teams. - Policies and protocols should be in place to ensure confidentiality and improve information sharing with carers – this is in place within our teams in the Trust. - Defined roles (Carer link workers) responsible for carers should be in place – this is in place within our teams. - Carers should be “introduced” to the service and provided with a range of information. We are capturing this on the wards with our carers link nurses and primary nurses offering one to one time with carers within 72 hours of patient admission to the ward. - A range of carer support services should be available to which to offer or signpost carers.”

Source location

2021-0094-Response-from-Littlemore-Mental-Health-Centre-Redacted
Page 3 · response
Published 13 April 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

Carry out directorate quality-improvement work on working with families to improve engagement and embed the Triangle of Care.

Verbatim wording from the response

“In addition to the above work, we currently have several initiatives underway to support our work to improve the quality of engagement with families. The Trust’s Buckinghamshire Mental Health directorate is leading Trust quality improvement work within the next 12 months on working with families, the goal of which is to improve our engagement and embrace the Triangle of Care.”

Source location

2021-0094-Response-from-Littlemore-Mental-Health-Centre-Redacted
Page 2 · response
Published 13 April 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

Review and relaunch the Trust carers’ strategy.

Verbatim wording from the response

“- Staff should be aware of carers and trained to engage with carers more effectively. The Trust has reviewed and re-launched the Trust’s carers’ strategy. Carers awareness training forms part of the carers’ strategy being rolled out within our teams. - Policies and protocols should be in place to ensure confidentiality and improve information sharing with carers – this is in place within our teams in the Trust. - Defined roles (Carer link workers) responsible for carers should be in place – this is in place within our teams. - Carers should be “introduced” to the service and provided with a range of information. We are capturing this on the wards with our carers link nurses and primary nurses offering one to one time with carers within 72 hours of patient admission to the ward. - A range of carer support services should be available to which to offer or signpost carers.”

Source location

2021-0094-Response-from-Littlemore-Mental-Health-Centre-Redacted
Page 3 · response
Published 13 April 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

Offer carers ward-based introductions and one-to-one time with carer link nurses and primary nurses within 72 hours of admission.

Verbatim wording from the response

“- Staff should be aware of carers and trained to engage with carers more effectively. The Trust has reviewed and re-launched the Trust’s carers’ strategy. Carers awareness training forms part of the carers’ strategy being rolled out within our teams. - Policies and protocols should be in place to ensure confidentiality and improve information sharing with carers – this is in place within our teams in the Trust. - Defined roles (Carer link workers) responsible for carers should be in place – this is in place within our teams. - Carers should be “introduced” to the service and provided with a range of information. We are capturing this on the wards with our carers link nurses and primary nurses offering one to one time with carers within 72 hours of patient admission to the ward. - A range of carer support services should be available to which to offer or signpost carers.”

Source location

2021-0094-Response-from-Littlemore-Mental-Health-Centre-Redacted
Page 3 · response
Published 13 April 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

Maintain defined carer link worker roles responsible for supporting carers within Trust teams.

Verbatim wording from the response

“- Staff should be aware of carers and trained to engage with carers more effectively. The Trust has reviewed and re-launched the Trust’s carers’ strategy. Carers awareness training forms part of the carers’ strategy being rolled out within our teams. - Policies and protocols should be in place to ensure confidentiality and improve information sharing with carers – this is in place within our teams in the Trust. - Defined roles (Carer link workers) responsible for carers should be in place – this is in place within our teams. - Carers should be “introduced” to the service and provided with a range of information. We are capturing this on the wards with our carers link nurses and primary nurses offering one to one time with carers within 72 hours of patient admission to the ward. - A range of carer support services should be available to which to offer or signpost carers.”

Source location

2021-0094-Response-from-Littlemore-Mental-Health-Centre-Redacted
Page 3 · response
Published 13 April 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

Review community mental health team operating procedures to reflect expected care coordinator standards.

Verbatim wording from the response

“- To review the standard operating policies for our community mental health teams to reflect the standards of practice expected in the role of care coordinator, which is pivotal to the delivery of care. - To review the induction process and package for both permanent and locum staff, with an aide memoire for both existing staff and new and locum staff to familiarise themselves with the role and expected standard of practice for the role and their team’s structure and processes. - To review the structure and process of care coordinator allocation within mental health community teams and the expectations of the role in order to ensure adherence of the Trust CPA policy. - To review the daily bed management and escalations meetings to capture care co-ordinator allocation and clear communication between the mental health community teams and inpatient teams.”

Source location

2021-0094-Response-from-Littlemore-Mental-Health-Centre-Redacted
Page 2 · response
Published 13 April 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

Maintain confidentiality and information-sharing policies and protocols for carers within Trust teams.

Verbatim wording from the response

“- Staff should be aware of carers and trained to engage with carers more effectively. The Trust has reviewed and re-launched the Trust’s carers’ strategy. Carers awareness training forms part of the carers’ strategy being rolled out within our teams. - Policies and protocols should be in place to ensure confidentiality and improve information sharing with carers – this is in place within our teams in the Trust. - Defined roles (Carer link workers) responsible for carers should be in place – this is in place within our teams. - Carers should be “introduced” to the service and provided with a range of information. We are capturing this on the wards with our carers link nurses and primary nurses offering one to one time with carers within 72 hours of patient admission to the ward. - A range of carer support services should be available to which to offer or signpost carers.”

Source location

2021-0094-Response-from-Littlemore-Mental-Health-Centre-Redacted
Page 3 · response
Published 13 April 2021

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