PFD report

Anna Mary Macfie Masson · Prevention of Future Deaths report

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Issued 15 Mar 2016•Central Hampshire

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 of the screening pathway to reliably identify people needing urgent treatment
  2. Failure to ensure consistent screening pathway practice across equivalent teams
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.2

  1. Action

    Conduct a randomised audit across CMHTs to assess governance of the standardised screening process.

    Stated by Hampshire and Isle of Wight Healthcare NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 15 March 2016.
  2. Action

    Standardise CMHT screening procedures, including appropriate staff expertise and multidisciplinary agreement of screening decisions.

    Stated by Hampshire and Isle of Wight Healthcare NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 15 March 2016.

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 the screening pathway to reliably identify people needing urgent treatment

Wider context from the report

“(1) I received the Trust’s Root Cause Analysis Report relating to the treatment of routine referrals by general practitioners which disclosed a recently introduced screening pathway process. The evidence showed that screening potential service users is conducted by relatively junior members of staff and my concern is whether this process is robust enough to identify those who need urgent treatment. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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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 ensure consistent screening pathway practice across equivalent teams

Wider context from the report

“(2) It was unclear from the evidence given whether the screening pathway applied only to the local community mental health team or across all equivalent teams employed by the Trust. I consider that there should be a consistent practice in all teams. ”

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

Conduct a randomised audit across CMHTs to assess governance of the standardised screening process.

Verbatim wording from the response

“Following completion of work to standardise the process we will undertake a randomised audit across the CMHTs to ensure governance around the screening process. We anticipate that this will be completed in September 2016.”

Source location

2016-0108-Response-by-Southern-Health-NHS-Trust
Page 1 · response
Published 15 March 2016

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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

Standardise CMHT screening procedures, including appropriate staff expertise and multidisciplinary agreement of screening decisions.

Verbatim wording from the response

“As part of the work identified during the investigation into the death of Mrs Masson, and following receipt of the Regulation 28 report the Trust has looked at the screening processes in all Adult Community Mental Health Teams (CMHT) and has identified that there is some variation across the Trust in terms of their screening processes. Consequently we have been working to review the CMHT Standard Operating Procedure (SOP) to ensure that a standard process is followed consistently across in all teams in the future to ensure the skill and expertise of those staff undertaking the screening is appropriate and that all decisions are agreed via a multi-disciplinary team discussion.”

Source location

2016-0108-Response-by-Southern-Health-NHS-Trust
Page 1 · response
Published 15 March 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.1

  1. 1

    Send referrals assessed as urgent to Acute Mental Health Teams for urgent prioritisation under the adult mental health pathway.

    Stated by Hampshire and Isle of Wight Healthcare NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 15 March 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

Send referrals assessed as urgent to Acute Mental Health Teams for urgent prioritisation under the adult mental health pathway.

Verbatim wording from the response

“Any referrals that are deemed urgent will be sent on to the Acute Mental Health Teams for urgent prioritisation as per the adult mental health pathway. This process was followed with Mrs Masson.”

Source location

2016-0108-Response-by-Southern-Health-NHS-Trust
Page 2 · response
Published 15 March 2016

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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