PFD report

Simon Peter REYNOLDS · Prevention of Future Deaths report

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Issued 24 Jul 2015•Avon

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
6

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
4

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 raised6

  1. Failure to appropriately assess service users' risk of suicide or self-harm
    Part of recurring concern: Unreliable assessment of suicide and self-harm risk
  2. Failure to record admission information in computerised Rio notes
    Part of recurring concern: Electronic patient records failing to make relevant clinical information available and actionablePart of recurring concern: Incomplete, inaccurate or unavailable clinical and care records
  3. Failure to appropriately communicate suicide or self-harm risk to other staff
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.4

  1. Action

    Revise 136 suite admission paperwork to incorporate Royal College of Psychiatrists’ risk headings for clearer detainee risk identification.

    Stated by Avon and Wiltshire Mental Health Partnership NHS TrustStated completedThe respondent said that this action was complete when they made their response on 24 July 2015.
  2. Action

    Review the Observation Policy against revised NICE guidance on observation levels and reflect the guidance in policy and practice.

    Stated by Avon and Wiltshire Mental Health Partnership NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 24 July 2015.
  3. Action

    Continue implementing Safewards interventions to reduce incidents of harm to self and others.

    Stated by Avon and Wiltshire Mental Health Partnership NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 24 July 2015.

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

  1. Position

    The RIO entry was made shortly after the incident, although documentation was delayed while staff managed the traumatic incident and debrief.

    Stated by Avon and Wiltshire Mental Health Partnership NHS TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

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 appropriately assess service users' risk of suicide or self-harm

Wider context from the report

“(3) I would also ask that you consider whether guidance or training ought to be provided to staff on how to set patient observation levels when being admitted onto Mason Unit; what factors to take into account when assessing a service users risk of suicide or self-harm and how to manage that risk appropriately and how to appropriately communicate that risk to other staff. ”

Is this part of a recurring concern?

Yes — Unreliable assessment of suicide and self-harm risk.

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 record admission information in computerised Rio notes

Wider context from the report

“(2) During the investigation I heard evidence that the nurse in charge made no record on the computerised Rio notes in relation to the admission. I would ask that you look into the appropriateness of this. ”

Is this part of a recurring concern?

Yes — Electronic patient records failing to make relevant clinical information available and actionable; Incomplete, inaccurate or unavailable clinical and care records.

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 appropriately communicate suicide or self-harm risk to other staff

Wider context from the report

“(3) I would also ask that you consider whether guidance or training ought to be provided to staff on how to set patient observation levels when being admitted onto Mason Unit; what factors to take into account when assessing a service users risk of suicide or self-harm and how to manage that risk appropriately and how to appropriately communicate that risk to other staff. ”

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

Failure to appropriately set patient observation levels at admission

Wider context from the report

“(3) I would also ask that you consider whether guidance or training ought to be provided to staff on how to set patient observation levels when being admitted onto Mason Unit; what factors to take into account when assessing a service users risk of suicide or self-harm and how to manage that risk appropriately and how to appropriately communicate that risk to other staff. ”

Is this part of a recurring concern?

Yes — Unreliable patient observation arrangements.

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 appropriately manage suicide or self-harm risk

Wider context from the report

“(3) I would also ask that you consider whether guidance or training ought to be provided to staff on how to set patient observation levels when being admitted onto Mason Unit; what factors to take into account when assessing a service users risk of suicide or self-harm and how to manage that risk appropriately and how to appropriately communicate that risk to other staff. ”

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 documented risk assessments at admission onto Mason Unit

Wider context from the report

“(1) I heard evidence that there is no documented risk assessment produced at the time of a service user's admission onto Mason Unit. I would ask that you review whether this is still appropriate. ”

Is this part of a recurring concern?

Yes — Unreliable admission assessment of patients; Unreliable completion of admission documentation.

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

Revise 136 suite admission paperwork to incorporate Royal College of Psychiatrists’ risk headings for clearer detainee risk identification.

Verbatim wording from the response

“Documented Risk Assessment It is our policy and standard to have a risk assessment completed at the time of admission. In Mr Reynolds’s case, a risk assessment had taken place with risk indicators linked from the progress notes to the risk assessment, however, this was not in a clear form. The admission paperwork for the 136 suite has been revised to incorporate the risk headings recommended by the Royal College of Psychiatrists. The adoption of this new paperwork ensures risks are clearly identified for detainees and its success will be evaluated in 3 months.”

Source location

2015-0296-Avon-and-Wiltshire-NHS-Trust
Page 1 · response
Published 24 July 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

Review the Observation Policy against revised NICE guidance on observation levels and reflect the guidance in policy and practice.

Verbatim wording from the response

“• Reviewing our Observation Policy to take account of revised guidance from the National Institute for Health and Care Excellence - “NICE NG10 Violence and aggression: short-term management in mental health, health and community settings”. This guidance includes definitions on the levels of observations which need to be reflected in our policy and practice.”

Source location

2015-0296-Avon-and-Wiltshire-NHS-Trust
Page 2 · response
Published 24 July 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

Continue implementing Safewards interventions to reduce incidents of harm to self and others.

Verbatim wording from the response

“• Continue the implementation of the ‘Safewards’ interventions already underway. Research has demonstrated that incidents of harm to self and others can be reduced through the implementation of the ‘Safewards’ Interventions as observation alone is insufficient and can increase risks.”

Source location

2015-0296-Avon-and-Wiltshire-NHS-Trust
Page 2 · response
Published 24 July 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

Review Place of Safety staffing levels through the Safer Staffing initiative to support timely observations and information recording.

Verbatim wording from the response

“• Reviewing staffing levels on the Place of Safety suite as part of the wider national Safer Staffing initiative, to ensure optimal staffing levels at all times, which will in turn support timely observations and recording of information.”

Source location

2015-0296-Avon-and-Wiltshire-NHS-Trust
Page 2 · response
Published 24 July 2015

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

The RIO entry was made shortly after the incident, although documentation was delayed while staff managed the traumatic incident and debrief.

Verbatim wording from the response

“Record on Rio The nurse-in-charge should have made an entry on the RIO record. Staff are encouraged to make their written record in as close a proximity to any assessment or event taking place as possible. Since the inquest, we have examined the audit trail of entries on RIO and determined that the entry was made on RIO at 00:11 hours, which was not long after staff had finished dealing with the incident and participating in the debrief. The day-time nurse in charge did not go off duty until 23.00 hours (one and a half hours beyond the end of her shift) in order to handover all necessary information and support staff.”

Source location

2015-0296-Avon-and-Wiltshire-NHS-Trust
Page 1 · response
Published 24 July 2015

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

Observation alone is insufficient and may increase risks; reducing harm also requires Safewards interventions.

Verbatim wording from the response

“• Continue the implementation of the ‘Safewards’ interventions already underway. Research has demonstrated that incidents of harm to self and others can be reduced through the implementation of the ‘Safewards’ Interventions as observation alone is insufficient and can increase risks.”

Source location

2015-0296-Avon-and-Wiltshire-NHS-Trust
Page 2 · response
Published 24 July 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