PFD report

Mark Ravensdale · Prevention of Future Deaths report

Pin Get email alerts Request correction

Issued 16 May 2023•South Yorkshire (Western)

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
1

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.

Open published report

Concerns and recipient responses

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

Concerns raised1

  1. Failure of mental health services to directly assess mental health conditions
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

    Review the Single Point of Access triage process in response to the identified concern.

    Stated by South West Yorkshire Partnership Teaching NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 4 August 2025.
  2. Action

    Develop and implement a triage checklist, using Plan-Do-Study-Act cycles, to identify when direct contact may be clinically indicated.

    Stated by South West Yorkshire Partnership Teaching NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 4 August 2025.
  3. Action

    Undertake an initial study of the triage checklist’s impact on service and care delivery after six months of implementation.

    Stated by South West Yorkshire Partnership Teaching NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 4 August 2025.

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 of mental health services to directly assess mental health conditions

Wider context from the report

“There were no attempts by mental health services to speak to Mark directly to properly and adequately assess his mental health condition. ”

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

Review the Single Point of Access triage process in response to the identified concern.

Verbatim wording from the response

“Following receipt of the Regulation 28 report the Trust undertook a review of the SPA triage process specific to your concern, led by the Associate Director of Operations, Adults and Older People Mental Health Care Group.”

Source location

Response from South West Yorkshire Partnership NHS Trust
Page 2 · response
Published 4 August 2025

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 and implement a triage checklist, using Plan-Do-Study-Act cycles, to identify when direct contact may be clinically indicated.

Verbatim wording from the response

“It was identified that, although the outcome of any triage process is reached based upon an evidence-based approach in line with the UK Mental Health Triage (MHT) Scale Guidelines and a practitioner’s own clinical assessment, further guidance would support a practitioner to identify when direct contact with the person referred may be clinically indicated. The Trust will therefore develop and implement a triage checklist in respect of the review’s findings.”

Source location

Response from South West Yorkshire Partnership NHS Trust
Page 2 · response
Published 4 August 2025

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

Undertake an initial study of the triage checklist’s impact on service and care delivery after six months of implementation.

Verbatim wording from the response

“An initial study of the triage checklist impact upon service and care delivery will be undertaken following 6 months of the checklist’s implementation, with appropriate actions taken as identified by the study.”

Source location

Response from South West Yorkshire Partnership NHS Trust
Page 2 · response
Published 4 August 2025

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