PFD report

Amy El-Keria · Prevention of Future Deaths report

Pin Get email alerts Request correction

Issued 3 Oct 2016•West Sussex

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
5

Raised in this report

Recipients
2

Named on the report

Responses found
3

Of 2 recipients

Stated actions
29

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

Open published report

Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised5

  1. Failure to assess and provide support for family contact when children are placed far from home
    Part of recurring concern: Unreliable Section 17 support and discharge-planning arrangements for children in need
  2. Inadequate staffing levels for one-to-one care in inpatient CAMHS units
    Part of recurring concern: Insufficient CAMHS staffing capacity and competence for safe carePart of recurring concern: Insufficient staffing capacity for required one-to-one patient supportPart of recurring concern: Unsafe provision of one-to-one care
  3. Shortage of acute mental health beds near young people's homes
    Part of recurring concern: Insufficient psychiatric inpatient bed capacity
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

    Publish and maintain the updated threshold guidance on the council, safeguarding board, and Children’s Social Care procedure websites.

    Stated by Mary Harpley, Chief ExecutiveStated completedThe respondent said that this action was complete when they made their response on 3 October 2016.
  2. Action

    Disseminate the updated information across Children’s Social Care and deliver refresher briefings to relevant managers, practitioners, social workers, and staff.

    Stated by Mary Harpley, Chief ExecutiveStated plannedThe respondent said that this action was planned when they made their response on 3 October 2016.
  3. Action

    Update Thresholds Guidance and Assessment Protocols to address duties for children placed away from home, mental health inpatient care, assessments, and family contact.

    Stated by Mary Harpley, Chief ExecutiveStated completedThe respondent said that this action was complete when they made their response on 3 October 2016.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.2

  1. Position

    Existing staffing reviews, multidisciplinary support, on-call arrangements and staff redeployment are considered sufficient to determine appropriate staffing levels.

    Stated by Priory GroupExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so 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 assess and provide support for family contact when children are placed far from home

Wider context from the report

“(2) Social Services clearly have a vital role to play in ensuring family contact where a child is placed far from their family home where difficulties arise. There was no assessment carried out to assess whether there was any need to provide support to a child in need under Section 17 Children Act 1989 even when Amy’s mother had specifically raised the difficulties she was having with contact with Amy, including the cost of travel, with her support worker. ”

Is this part of a recurring concern?

Yes — Unreliable Section 17 support and discharge-planning arrangements for children in need.

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

Inadequate staffing levels for one-to-one care in inpatient CAMHS units

Wider context from the report

“(1) The Jury in this Inquest found that the staffing levels, which were in line with the ONIC staffing ratio, were inadequate to give Amy sufficient one to one time in accordance with her care plan. It is understood that in December 2014 the Department of Health tasked NICE with developing guidance on staffing levels for inpatient CAMHS units but this appears to have been discontinued. There is currently no national guidance on staffing levels for inpatient CAHMS ”

Is this part of a recurring concern?

Yes — Insufficient CAMHS staffing capacity and competence for safe care; Insufficient staffing capacity for required one-to-one patient support; Unsafe provision of one-to-one care.

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

Shortage of acute mental health beds near young people's homes

Wider context from the report

“(2) There continues to be a shortage of acute mental health beds for young people close to where they live. This means that families have to travel long distances to visit their child and they are unable to provide the necessary day to day support to their child. Family support can play a very significant role in managing risk of suicide by avoiding and mitigating distress. ”

Is this part of a recurring concern?

Yes — Insufficient psychiatric inpatient bed capacity.

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 maintain an ongoing welfare-support role for children placed at external facilities

Wider context from the report

“(1) The evidence given at the Inquest showed that there was a clear misapprehension by Hounslow Social Services as to their role in supporting Amy whilst at Ticehurst. It appears that Social services did not appreciate their important ongoing role to ensure Amy’s welfare whilst placed at Ticehurst████████ the Court expert, gave evidence that Hounslow may have seen this as a health funded placement as a stand-alone intervention that did not require their input. ”

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

Lack of national staffing guidance for inpatient CAMHS units

Wider context from the report

“(1) The Jury in this Inquest found that the staffing levels, which were in line with the ONIC staffing ratio, were inadequate to give Amy sufficient one to one time in accordance with her care plan. It is understood that in December 2014 the Department of Health tasked NICE with developing guidance on staffing levels for inpatient CAMHS units but this appears to have been discontinued. There is currently no national guidance on staffing levels for inpatient CAHMS ”

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

Publish and maintain the updated threshold guidance on the council, safeguarding board, and Children’s Social Care procedure websites.

Verbatim wording from the response

“The threshold document is available to the public on the council’s website and specifically on its Local Safeguarding Children’s Board site. The document is public facing but is primarily aimed at assisting those professionals working with children to understand how thresholds are applied and how child protection professionals make decisions in respect of appropriate action. Assistance to children in need under S17 of the Children Act 1989 for children placed in a hospital or other setting is referenced at section 3.9 (pages 12-14) under the headings ‘Children Receiving Tier 4 Inpatient Provision’ and ‘Children Act 1989 Section 85 & 86 Duties’.”

Source location

Response from London Borough of Hounslow
Page 2 · response
Published 3 October 2016

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

Disseminate the updated information across Children’s Social Care and deliver refresher briefings to relevant managers, practitioners, social workers, and staff.

Verbatim wording from the response

“The London Borough of Hounslow has re-drafted and updated its Thresholds Guidance & Assessment Protocols to ensure specific reference is made to these matters. Advice was sought from Mental Health professionals as part of this process. The London Borough of Hounslow will ensure that this information is disseminated across Children’s Social Care, and that refresher and update briefing will be delivered to all relevant social workers and staff. The information will be disseminated across Children’s Social Care teams the week of 28/11/2016 and Heads of Service and Team Managers will ensure that all managers and practitioners are fully briefed. Information will be shared by Heads of Service at their next Management Meetings and with social work staff at their next Team Meetings.”

Source location

Response from London Borough of Hounslow
Page 1 · response
Published 3 October 2016

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

Update Thresholds Guidance and Assessment Protocols to address duties for children placed away from home, mental health inpatient care, assessments, and family contact.

Verbatim wording from the response

“The London Borough of Hounslow has re-drafted and updated its Thresholds Guidance & Assessment Protocols to ensure specific reference is made to these matters. Advice was sought from Mental Health professionals as part of this process. The London Borough of Hounslow will ensure that this information is disseminated across Children’s Social Care, and that refresher and update briefing will be delivered to all relevant social workers and staff. The information will be disseminated across Children’s Social Care teams the week of 28/11/2016 and Heads of Service and Team Managers will ensure that all managers and practitioners are fully briefed. Information will be shared by Heads of Service at their next Management Meetings and with social work staff at their next Team Meetings.”

Source location

Response from London Borough of Hounslow
Page 1 · response
Published 3 October 2016

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 comprehensive community-based mental health service pathways and standards to support treatment closer to home.

Verbatim wording from the response

“However, we should also be seeking to avoid unnecessary admissions to hospital wherever possible. That is why the Government is developing a comprehensive set of community-based mental health service pathways and standards so that more people can be treated in the community closer to home. We have also invested £400 million to improve crisis care services in the community so that people receive the right care”

Source location

2016-0347-Response-by-Department-of-Health
Page 2 · response
Published 3 October 2016

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

Invest £400 million to improve community crisis-care services.

Verbatim wording from the response

“However, we should also be seeking to avoid unnecessary admissions to hospital wherever possible. That is why the Government is developing a comprehensive set of community-based mental health service pathways and standards so that more people can be treated in the community closer to home. We have also invested £400 million to improve crisis care services in the community so that people receive the right care”

Source location

2016-0347-Response-by-Department-of-Health
Page 2 · response
Published 3 October 2016

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

Existing staffing reviews, multidisciplinary support, on-call arrangements and staff redeployment are considered sufficient to determine appropriate staffing levels.

Verbatim wording from the response

“We note your comments in relation to the QNIC guidance published by the Royal College of Psychiatrists and we consider that this is still an appropriate reference point for the staffing of CAMHS units and continues to be used by many providers in determining and monitoring appropriate staffing levels.”

Source location

2016-0347-Response-by-Priory-Group
Page 1 · response
Published 3 October 2016

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

Existing staffing guidance, continual staffing reviews, multidisciplinary support and escalation arrangements are considered sufficient to determine appropriate staffing levels.

Verbatim wording from the response

“We note your comments in relation to the QNІC guidance published by the Royal College of Psychiatrists and we consider that this is still an appropriate reference point for the staffing of CAMHS units and continues to be used by many providers in determining and monitoring appropriate staffing levels.”

Source location

2016-0347 - Response from Priory
Page 1 · response
Published 3 October 2016

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.24

  1. 1

    Retain an ALS and resuscitation expert to train and coach staff and help develop and implement emergency scenarios with objective feedback.

    Stated by Priory GroupStated plannedThe respondent said that this action was planned when they made their response on 3 October 2016.
  2. 2

    Complete staff briefings on using the enhanced risk assessment tool.

    Stated by Priory GroupStated in progressThe respondent said that this action was in progress when they made their response on 3 October 2016.
  3. 3

    Use enhanced observation recording forms with clearer instructions on required records.

    Stated by Priory GroupStated completedThe respondent said that this action was complete when they made their response on 3 October 2016.
  4. 4

    Use the enhanced risk assessment tool to assess behavioural risk and involve patients in understanding and managing their risks.

    Stated by Priory GroupStated completedThe respondent said that this action was complete when they made their response on 3 October 2016.
  5. 5

    Deliver a National Framework on Learning from Deaths for NHS providers to standardise identification, reporting, review, investigation and learning.

    Stated by Department of Health and Social CareStated in progressThe respondent said that this action was in progress when they made their response on 3 October 2016.
  6. 6

    Revise the Mental Health Act Code of Practice to require robust multidisciplinary care plans and effective risk assessment.

    Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 3 October 2016.
  7. 7

    Implement measures to record and monitor deaths of patients under inpatient child and adolescent mental health services, with each death directly reported to Ministers.

    Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 3 October 2016.
  8. 8

    Commission a review of how deaths in NHS settings are investigated and learned from to prevent further tragedies.

    Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 3 October 2016.
  9. 9

    Develop community-based mental health service pathways and standards to support treatment closer to home.

    Stated by Department of Health and Social CareStated in progressThe respondent said that this action was in progress when they made their response on 3 October 2016.
  10. 10

    Invest £400 million to improve community crisis care services and provide appropriate care closer to home.

    Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 3 October 2016.
  11. 11

    Publish good-practice guidance on assessing and managing risk in mental health services.

    Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 3 October 2016.
  12. 12

    Deliver an additional knowledge-refresh development session for managers, Independent Reviewing Officers, and Advanced Practitioners at the next Managers’ Forum.

    Stated by Mary Harpley, Chief ExecutiveStated plannedThe respondent said that this action was planned when they made their response on 3 October 2016.
  13. 13

    Monitor local compliance with observation procedures through unannounced out-of-hours internal audits.

    Stated by Priory GroupStated completedThe respondent said that this action was complete when they made their response on 3 October 2016.
  14. 14

    Retain an ALS and resuscitation expert to train and coach nursing and medical staff and support development and implementation of emergency scenarios with objective feedback.

    Stated by Priory GroupStated plannedThe respondent said that this action was planned when they made their response on 3 October 2016.
  15. 15

    Conduct monthly simulation drills covering varied basic and intermediate life-support emergency scenarios for all staff.

    Stated by Priory GroupStated completedThe respondent said that this action was complete when they made their response on 3 October 2016.
  16. 16

    Brief staff on using the enhanced Risk Assessment Tool.

    Stated by Priory GroupStated in progressThe respondent said that this action was in progress when they made their response on 3 October 2016.
  17. 17

    Use enhanced observation recording forms with clearer recording instructions.

    Stated by Priory GroupStated completedThe respondent said that this action was complete when they made their response on 3 October 2016.
  18. 18

    Use the enhanced Risk Assessment Tool to assess behavioural risk before admission and involve patients in understanding and managing their risks.

    Stated by Priory GroupStated completedThe respondent said that this action was complete when they made their response on 3 October 2016.
  19. 19

    Improve recording and monitoring of inpatient CAMHS deaths through direct reporting of every death to Ministers.

    Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 3 October 2016.
  20. 20

    Revise the Mental Health Act Code of Practice to require robust multidisciplinary care planning and effective risk assessment.

    Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 3 October 2016.
  21. 21

    Commission the Care Quality Commission to review how NHS deaths are investigated and learned from.

    Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 3 October 2016.
  22. 22

    Publish good-practice guidance on assessing and managing risk in mental health services.

    Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 3 October 2016.
  23. 23

    Implement a programme responding to recommendations on learning from deaths, beginning with a national framework for NHS providers.

    Stated by Department of Health and Social CareStated in progressThe respondent said that this action was in progress when they made their response on 3 October 2016.
  24. 24

    Strengthen CQC provider assessments by including learning from deaths.

    Stated by Department of Health and Social CareStated plannedThe respondent said that this action was planned when they made their response on 3 October 2016.

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

Retain an ALS and resuscitation expert to train and coach staff and help develop and implement emergency scenarios with objective feedback.

Verbatim wording from the response

“Having reviewed your comments in relation to ALS training carefully, we consider there is greater overall benefit for the hospital if we retain an expert in ALS/resuscitation who will deliver training and coaching to our staff. The expert is to be retained under appropriate contractual arrangements and will provide face-to-face training for nursing and medical staff and will work with the hospital management team on developing and implementing the emergency scenarios and provide objective feedback.”

Source location

2016-0347-Response-by-Priory-Group
Page 2 · response
Published 3 October 2016

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

Complete staff briefings on using the enhanced risk assessment tool.

Verbatim wording from the response

“I am pleased to advise you that an enhanced Risk Assessment Tool was launched on 28 November 2016 and that staff briefings in relation to using the tool are underway. The new tool enables a better assessment of behavioural risk prior to admission and encourages patients to become more involved in understanding their risks and how to manage them. Feedback from our staff about the tool has been very positive.”

Source location

2016-0347-Response-by-Priory-Group
Page 2 · response
Published 3 October 2016

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

Use enhanced observation recording forms with clearer instructions on required records.

Verbatim wording from the response

“In common with all healthcare providers and as part of its commitment to continuous improvement, Priory Group keeps all of its operational policies and procedures under constant review including in relation to observation and engagement. Observation recording forms have been enhanced and are now more user friendly with clear instructions on what should be recorded. We have also endeavoured to make the policy clearer in relation to information sharing. Local site compliance with observation procedures is monitored via out-of-hours unannounced internal audits.”

Source location

2016-0347-Response-by-Priory-Group
Page 2 · response
Published 3 October 2016

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

Use the enhanced risk assessment tool to assess behavioural risk and involve patients in understanding and managing their risks.

Verbatim wording from the response

“I am pleased to advise you that an enhanced Risk Assessment Tool was launched on 28 November 2016 and that staff briefings in relation to using the tool are underway. The new tool enables a better assessment of behavioural risk prior to admission and encourages patients to become more involved in understanding their risks and how to manage them. Feedback from our staff about the tool has been very positive.”

Source location

2016-0347-Response-by-Priory-Group
Page 2 · response
Published 3 October 2016

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 a National Framework on Learning from Deaths for NHS providers to standardise identification, reporting, review, investigation and learning.

Verbatim wording from the response

“The Secretary of State accepted the CQC’s recommendations for improvement and a programme to deliver his commitments is underway. The first stage will be the delivery this year of a National Framework on Learning from Deaths for NHS providers. The aim is to standardise and improve practice across providers by providing clear expectations in relation to identifying, reporting, reviewing, investigating and learning from deaths and, significantly, engaging with bereaved families and carers. From April 2017, Trusts will be required to publish specified information on deaths each quarter, including estimates of how many deaths were judged more likely than not to have been associated with problems in care. Trusts will also be required to publish evidence of learning and action as a result of the information.”

Source location

2016-0347 - Response from Department of Health and Social Care
Page 3 · response
Published 3 October 2016

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

Revise the Mental Health Act Code of Practice to require robust multidisciplinary care plans and effective risk assessment.

Verbatim wording from the response

“The Government revised the Mental Health Act 183 Code of Practice in 2015, which we expect all mental health providers to implement. The Code of Practice is clear that patients should have in place a robust care plan developed by a multi-disciplinary team and that this should include effective risk assessment.”

Source location

2016-0347 - Response from Department of Health and Social Care
Page 2 · response
Published 3 October 2016

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

Implement measures to record and monitor deaths of patients under inpatient child and adolescent mental health services, with each death directly reported to Ministers.

Verbatim wording from the response

“In addition, as a result of cases such as that of Miss El-Keria’s, earlier this year I set out measures for how we will improve the recording and monitoring of deaths of patients under the care of inpatient child and adolescent mental health services, with every death now directly reported to Ministers.”

Source location

2016-0347 - Response from Department of Health and Social Care
Page 4 · response
Published 3 October 2016

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

Commission a review of how deaths in NHS settings are investigated and learned from to prevent further tragedies.

Verbatim wording from the response

“Every death of a person in a mental health setting is a tragedy and every patient has the right to expect high quality and safe care. This is why we commissioned the Care Quality Commission (CQC) to review the way in which deaths of people in NHS settings are investigated and learned from to avoid further tragedies.”

Source location

2016-0347 - Response from Department of Health and Social Care
Page 3 · response
Published 3 October 2016

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 community-based mental health service pathways and standards to support treatment closer to home.

Verbatim wording from the response

“However, we should also be seeking to avoid unnecessary admissions to hospital wherever possible. That is why the Government is developing a comprehensive set of community-based mental health service pathways and standards so that more people can be treated in the community closer to home. We have also invested £400 million to improve crisis care services in the community so that people receive the right care”

Source location

2016-0347 - Response from Department of Health and Social Care
Page 2 · response
Published 3 October 2016

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

Invest £400 million to improve community crisis care services and provide appropriate care closer to home.

Verbatim wording from the response

“However, we should also be seeking to avoid unnecessary admissions to hospital wherever possible. That is why the Government is developing a comprehensive set of community-based mental health service pathways and standards so that more people can be treated in the community closer to home. We have also invested £400 million to improve crisis care services in the community so that people receive the right care”

Source location

2016-0347 - Response from Department of Health and Social Care
Page 2 · response
Published 3 October 2016

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

Publish good-practice guidance on assessing and managing risk in mental health services.

Verbatim wording from the response

“The Department of Health published good practice guidance on assessing and managing risk in mental health in 2009. This can be accessed through the GOV.UK website at the following address: https://www.gov.uk/government/publications/assessing-and-managing-risk-in-mental-health-services”

Source location

2016-0347 - Response from Department of Health and Social Care
Page 2 · response
Published 3 October 2016

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 an additional knowledge-refresh development session for managers, Independent Reviewing Officers, and Advanced Practitioners at the next Managers’ Forum.

Verbatim wording from the response

“An additional development session for refreshing knowledge will be delivered to Managers, Independent Reviewing Officers, and Advanced Practitioners at the next Managers’ Forum in the New Year.”

Source location

Response from London Borough of Hounslow
Page 1 · response
Published 3 October 2016

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

Monitor local compliance with observation procedures through unannounced out-of-hours internal audits.

Verbatim wording from the response

“In common with all healthcare providers and as part of its commitment to continuous improvement, Priory Group keeps all of its operational policies and procedures under constant review including in relation to observation and engagement. Observation recording forms have been enhanced and are now more user friendly with clear instructions on what should be recorded. We have also endeavoured to make the policy clearer in relation to information sharing. Local site compliance with observation procedures is monitored via out-of-hours unannounced internal audits.”

Source location

2016-0347 - Response from Priory
Page 2 · response
Published 3 October 2016

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

Retain an ALS and resuscitation expert to train and coach nursing and medical staff and support development and implementation of emergency scenarios with objective feedback.

Verbatim wording from the response

“Having reviewed your comments in relation to ALS training carefully, we consider there is greater overall benefit for the hospital if we retain an expert in ALS/resuscitation who will deliver training and coaching to our staff. The expert is to be retained under appropriate contractual arrangements and will provide face-to-face training for nursing and medical staff and will work with the hospital management team on developing and implementing the emergency scenarios and provide objective feedback.”

Source location

2016-0347 - Response from Priory
Page 2 · response
Published 3 October 2016

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

Conduct monthly simulation drills covering varied basic and intermediate life-support emergency scenarios for all staff.

Verbatim wording from the response

“Please note that in relation to BLS and ILS, monthly simulation drills are undertaken and these involve all staff and involve a variety of different emergency life support scenarios. Feedback from the drills has been very positive and indicates that staff are continually putting into practise the skills that they have been taught.”

Source location

2016-0347 - Response from Priory
Page 2 · response
Published 3 October 2016

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

Brief staff on using the enhanced Risk Assessment Tool.

Verbatim wording from the response

“I am pleased to advise you that an enhanced Risk Assessment Tool was launched on 28 November 2016 and that staff briefings in relation to using the tool are underway. The new tool enables a better assessment of behavioural risk prior to admission and encourages patients to become more involved in understanding their risks and how to manage them. Feedback from our staff about the tool has been very positive.”

Source location

2016-0347 - Response from Priory
Page 2 · response
Published 3 October 2016

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

Use enhanced observation recording forms with clearer recording instructions.

Verbatim wording from the response

“In common with all healthcare providers and as part of its commitment to continuous improvement, Priory Group keeps all of its operational policies and procedures under constant review including in relation to observation and engagement. Observation recording forms have been enhanced and are now more user friendly with clear instructions on what should be recorded. We have also endeavoured to make the policy clearer in relation to information sharing. Local site compliance with observation procedures is monitored via out-of-hours unannounced internal audits.”

Source location

2016-0347 - Response from Priory
Page 2 · response
Published 3 October 2016

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

Use the enhanced Risk Assessment Tool to assess behavioural risk before admission and involve patients in understanding and managing their risks.

Verbatim wording from the response

“I am pleased to advise you that an enhanced Risk Assessment Tool was launched on 28 November 2016 and that staff briefings in relation to using the tool are underway. The new tool enables a better assessment of behavioural risk prior to admission and encourages patients to become more involved in understanding their risks and how to manage them. Feedback from our staff about the tool has been very positive.”

Source location

2016-0347 - Response from Priory
Page 2 · response
Published 3 October 2016

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

Improve recording and monitoring of inpatient CAMHS deaths through direct reporting of every death to Ministers.

Verbatim wording from the response

“In addition, as a result of cases such as that of Miss El-Keria’s, earlier this year I set out measures for how we will improve the recording and monitoring of deaths of patients under the care of inpatient child and adolescent mental health services, with every death now directly reported to Ministers.”

Source location

2016-0347-Response-by-Department-of-Health
Page 4 · response
Published 3 October 2016

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

Revise the Mental Health Act Code of Practice to require robust multidisciplinary care planning and effective risk assessment.

Verbatim wording from the response

“The Government revised the Mental Health Act 183 Code of Practice in 2015, which we expect all mental health providers to implement. The Code of Practice is clear that patients should have in place a robust care plan developed by a multi-disciplinary team and that this should include effective risk assessment.”

Source location

2016-0347-Response-by-Department-of-Health
Page 2 · response
Published 3 October 2016

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

Commission the Care Quality Commission to review how NHS deaths are investigated and learned from.

Verbatim wording from the response

“Every death of a person in a mental health setting is a tragedy and every patient has the right to expect high quality and safe care. This is why we commissioned the Care Quality Commission (CQC) to review the way in which deaths of people in NHS settings are investigated and learned from to avoid further tragedies.”

Source location

2016-0347-Response-by-Department-of-Health
Page 3 · response
Published 3 October 2016

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

Publish good-practice guidance on assessing and managing risk in mental health services.

Verbatim wording from the response

“The Department of Health published good practice guidance on assessing and managing risk in mental health in 2009. This can be accessed through the GOV.UK website at the following address: https://www.gov.uk/government/publications/assessing-and-managing-risk-in-mental-health-services”

Source location

2016-0347-Response-by-Department-of-Health
Page 2 · response
Published 3 October 2016

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

Implement a programme responding to recommendations on learning from deaths, beginning with a national framework for NHS providers.

Verbatim wording from the response

“The Secretary of State accepted the CQC’s recommendations for improvement and a programme to deliver his commitments is underway. The first stage will be the delivery this year of a National Framework on Learning from Deaths for NHS providers. The aim is to standardise and improve practice across providers by providing clear expectations in relation to identifying, reporting, reviewing, investigating and learning from deaths, and significantly, engaging with bereaved families and carers. From April 2017, Trusts will be required to publish specified information on deaths each quarter, including estimates of how many deaths were judged more likely than not to have been associated with problems in care. Trusts will also be required to publish evidence of learning and action as a result of the information.”

Source location

2016-0347-Response-by-Department-of-Health
Page 3 · response
Published 3 October 2016

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 CQC provider assessments by including learning from deaths.

Verbatim wording from the response

“This increased transparency, through improved data collection and reporting, is about supporting a systemic, NHS-wide approach to learning from deaths. The CQC will also strengthen its assessment of providers by covering learning from deaths.”

Source location

2016-0347-Response-by-Department-of-Health
Page 3 · response
Published 3 October 2016

Open published response
Back to top

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