PFD report

LEAH LEVINE · Prevention of Future Deaths report

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Issued 11 Mar 2015•Manchester South

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
2

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
3

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 clearly define temporary hospital leave conditions, supervision responsibilities and observation requirements
    Part of recurring concern: Unsafe management of inpatient leave and absence
  2. Failure to document and provide temporary hospital leave arrangements to those taking the patient from hospital
    Part of recurring concern: Unsafe management of inpatient leave and absence
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.3

  1. Action

    Implement the procedure for informal patients’ leave with family and friends by 31 May 2015.

    Stated by Greater Manchester Mental Health NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 11 March 2015.
  2. Action

    Develop a procedure governing informal patients’ leave with family and friends, including medication, supervision, crisis planning and home-based treatment support considerations.

    Stated by Greater Manchester Mental Health NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 11 March 2015.
  3. Action

    Inform all inpatient nursing and medical staff about the procedure by 31 May 2015.

    Stated by Greater Manchester Mental Health NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 11 March 2015.

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 clearly define temporary hospital leave conditions, supervision responsibilities and observation requirements

Wider context from the report

“When it was negotiated by the family and friends, with the NHS Trust employees, that she could have temporary leave from the hospital, it was never clearly set out as to what the conditions of that leave should be: who should be responsible for supervising her: What the level and frequency of such supervision should be: what, if any, observation regime should be put in place: and nothing was reduced to writing and given to those taking her from the hospital. Consequent on the above, there was conflicting evidence from different members of the medical and nursing staff as to what exactly was expected and put forward as required. ”

Is this part of a recurring concern?

Yes — Unsafe management of inpatient leave and absence.

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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 document and provide temporary hospital leave arrangements to those taking the patient from hospital

Wider context from the report

“When it was negotiated by the family and friends, with the NHS Trust employees, that she could have temporary leave from the hospital, it was never clearly set out as to what the conditions of that leave should be: who should be responsible for supervising her: What the level and frequency of such supervision should be: what, if any, observation regime should be put in place: and nothing was reduced to writing and given to those taking her from the hospital. Consequent on the above, there was conflicting evidence from different members of the medical and nursing staff as to what exactly was expected and put forward as required. ”

Is this part of a recurring concern?

Yes — Unsafe management of inpatient leave and absence.

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

Implement the procedure for informal patients’ leave with family and friends by 31 May 2015.

Verbatim wording from the response

“I will therefore outline the action taken by the Trust to address the concern you have raised within your regulation 28. The Salford Directorate has developed a procedure that should be followed when Informal Patients are granted leave with family and friends. This procedure outlines the considerations by the Multidisciplinary team that need to be taken whilst granting leave for a service user in our care. These include medication management, supervision, crisis plan, home based treatment support if applicable. I enclose a copy of the procedure for your information. In order to share the learning from Ms Levine’s death and following the concerns raised during your inquest, the Directorate will inform all Inpatient Nursing and Medical of the procedure which will be implemented by the 31st May 2015.”

Source location

2015-0093-Response-by-Greater-Manchester-West-NHS
Page 1 · response
Published 11 March 2015

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Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Develop a procedure governing informal patients’ leave with family and friends, including medication, supervision, crisis planning and home-based treatment support considerations.

Verbatim wording from the response

“I will therefore outline the action taken by the Trust to address the concern you have raised within your regulation 28. The Salford Directorate has developed a procedure that should be followed when Informal Patients are granted leave with family and friends. This procedure outlines the considerations by the Multidisciplinary team that need to be taken whilst granting leave for a service user in our care. These include medication management, supervision, crisis plan, home based treatment support if applicable. I enclose a copy of the procedure for your information. In order to share the learning from Ms Levine’s death and following the concerns raised during your inquest, the Directorate will inform all Inpatient Nursing and Medical of the procedure which will be implemented by the 31st May 2015.”

Source location

2015-0093-Response-by-Greater-Manchester-West-NHS
Page 1 · response
Published 11 March 2015

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

Inform all inpatient nursing and medical staff about the procedure by 31 May 2015.

Verbatim wording from the response

“I will therefore outline the action taken by the Trust to address the concern you have raised within your regulation 28. The Salford Directorate has developed a procedure that should be followed when Informal Patients are granted leave with family and friends. This procedure outlines the considerations by the Multidisciplinary team that need to be taken whilst granting leave for a service user in our care. These include medication management, supervision, crisis plan, home based treatment support if applicable. I enclose a copy of the procedure for your information. In order to share the learning from Ms Levine’s death and following the concerns raised during your inquest, the Directorate will inform all Inpatient Nursing and Medical of the procedure which will be implemented by the 31st May 2015.”

Source location

2015-0093-Response-by-Greater-Manchester-West-NHS
Page 1 · response
Published 11 March 2015

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