David Clark · Prevention of Future Deaths report

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Issued 6 Feb 2020•Lancashire and Blackburn with Darwen

Published report and response evidence

This report’s concerns and statements found in recipients’ published responses. Statements are included even where no link to an individual concern is recorded. A link shows an evidence connection; it does not assign responsibility.

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Concerns
5

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
21

Described in responses

Recipients and published responses

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 raised5

  1. Lack of training on policy and procedure
  2. Failure to establish an appropriately sufficient action plan
  3. Failure to complete leave documentation fully and use correct forms
    Part of recurring concern: Unsafe management of inpatient leave and absence

Stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.21

  1. Lancashire & South Cumbria NHS Foundation Trust

    Implement the Section 17 leave audit and report compliance monthly through the Senior Leadership Team.

  2. Lancashire & South Cumbria NHS Foundation Trust

    Review Safety and Security handover arrangements, disseminate revised forms, and audit completion weekly.

  3. Lancashire & South Cumbria NHS Foundation Trust

    Review the Trust AWOL policy and procedure to reflect investigation learning.

  4. Lancashire & South Cumbria NHS Foundation Trust

    Share serious-incident and care-related learning with the Ward Manager and Matron through supervision.

  5. Lancashire & South Cumbria NHS Foundation Trust

    Audit Safety and Security documentation weekly at unit level.

  6. Lancashire & South Cumbria NHS Foundation Trust

    Roll out the RiO pre- and post-leave assessment form across the Trust.

  7. Lancashire & South Cumbria NHS Foundation Trust

    Audit ward use and completion of correct Safety and Security handover documentation.

  8. Lancashire & South Cumbria NHS Foundation Trust

    Make clinical risk assessment training mandatory for all clinical staff delivering mental health services.

  9. Lancashire & South Cumbria NHS Foundation Trust

    Undertake a rapid improvement event to review the Safety and Security role and revise documentation if required.

  10. Lancashire & South Cumbria NHS Foundation Trust

    Complete supervision for the Ward Manager and Matron on AWOL procedures.

  11. Lancashire & South Cumbria NHS Foundation Trust

    Establish a Ward Managers Task and Finish Group addressing policy and practice.

  12. Lancashire & South Cumbria NHS Foundation Trust

    Induct all new staff to Safety and Security procedures.

  13. Lancashire & South Cumbria NHS Foundation Trust

    Debrief staff involved in the care following learning from the inquest.

  14. Lancashire & South Cumbria NHS Foundation Trust

    Strengthen the action plan to incorporate additional views and oversee it through the Trust Quality Committee.

  15. Lancashire & South Cumbria NHS Foundation Trust

    Develop and agree an inpatient safety matrix audit tool covering Section 17 leave.

  16. Lancashire & South Cumbria NHS Foundation Trust

    Provide AWOL procedure training through inpatient development days and follow-up email communication.

  17. Lancashire & South Cumbria NHS Foundation Trust

    Share Safety and Security handover learning across the Trust.

  18. Lancashire & South Cumbria NHS Foundation Trust

    Issue a practice note reminding relevant staff of accountability for Mental Health Act documentation and Trust policy.

  19. Lancashire & South Cumbria NHS Foundation Trust

    Update the AWOL policy and procedure, including agreeing return times and initiating procedures when service users do not return.

  20. Lancashire & South Cumbria NHS Foundation Trust

    Monitor detained-patient Mental Health Act documentation daily and distribute status reports to wards.

  21. Lancashire & South Cumbria NHS Foundation Trust

    Use the pre- and post-leave assessment form in the RiO electronic care record across Secure Services.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.1

  1. Lancashire & South Cumbria NHS Foundation Trust

    Implementation of the Section 17 leave audit and Safety and Security role review was paused because of COVID-19.

    Unable to actThe respondent said that a constraint prevented them from taking the relevant action.

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 training on policy and procedure

Wider context from the report

“(4) That there was a lack of training on policy and procedure. ”

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 establish an appropriately sufficient action plan

Wider context from the report

“(5) That there remains outstanding an appropriately sufficient action plan. ”

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 complete leave documentation fully and use correct forms

Wider context from the report

“(1) That documentation in relation to leave was not completed fully and incorrect forms used ”

Is this part of a recurring concern?

Yes — Unsafe management of inpatient leave and absence.

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 follow the AWOL procedure

Wider context from the report

“(2) That the AWOL procedure was not followed. ”

Is this part of a recurring concern?

Yes — Unreliable AWOL response processes.

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 undertake handovers between Safety and Security workers

Wider context from the report

“(3) That a handover was not undertaken between Safety and Security workers. ”

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

Implement the Section 17 leave audit and report compliance monthly through the Senior Leadership Team.

Verbatim wording from the response

“o Section 17 leave - An inpatient safety matrix which will audit this practice at ward level includes a section of Section 17 Leave. The audit tool has been developed and agreed with Ward Managers (attachment 4). However implementation has been paused due to COVID 19 (new target date September 2020) once implemented compliance will be reported on a monthly basis through the Senior Leadership Team.”

Source location

2020-0023-Response-from-Lancashire-and-South-Cumbria-NHS-Foundation-Trust-Redacted
Page 1 · response
Published 8 February 2020

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 Safety and Security handover arrangements, disseminate revised forms, and audit completion weekly.

Verbatim wording from the response

“Unit Level: o The SaS handover has been reviewed and new forms disseminated which include the SaS worker agreeing that the handover has taken place. The SaS paperwork is audited weekly and demonstrates that handovers are consistently being undertaken (SaS handover documentation, attachment 9).”

Source location

2020-0023-Response-from-Lancashire-and-South-Cumbria-NHS-Foundation-Trust-Redacted
Page 2 · response
Published 8 February 2020

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 the Trust AWOL policy and procedure to reflect investigation learning.

Verbatim wording from the response

“Trust Level: o The Trust policy and procedure for AWOL has been reviewed and reflects the learning from the investigation (attachment 8).”

Source location

2020-0023-Response-from-Lancashire-and-South-Cumbria-NHS-Foundation-Trust-Redacted
Page 2 · response
Published 8 February 2020

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

Share serious-incident and care-related learning with the Ward Manager and Matron through supervision.

Verbatim wording from the response

“• Learning in relation to this serious incident and the concerns regarding the care of Mr Clark have been shared with the Ward Manager and the Matron in supervision on 19 February 2020 by the Head of Nursing, Mental Health.”

Source location

2020-0023-Response-from-Lancashire-and-South-Cumbria-NHS-Foundation-Trust-Redacted
Page 3 · response
Published 8 February 2020

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

Audit Safety and Security documentation weekly at unit level.

Verbatim wording from the response

“Unit Level o The Orchard WM and Matron are auditing compliance with Safety & Security (SaS) documentation weekly (attachment 2).”

Source location

2020-0023-Response-from-Lancashire-and-South-Cumbria-NHS-Foundation-Trust-Redacted
Page 1 · response
Published 8 February 2020

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

Roll out the RiO pre- and post-leave assessment form across the Trust.

Verbatim wording from the response

“o Work has been undertaken to the new electronic care record RiO which now includes a pre and post leave assessment form. This is in place in Secure Services and is to be rolled out across the Trust by March 2021.”

Source location

2020-0023-Response-from-Lancashire-and-South-Cumbria-NHS-Foundation-Trust-Redacted
Page 2 · response
Published 8 February 2020

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

Audit ward use and completion of correct Safety and Security handover documentation.

Verbatim wording from the response

“Trust Level: o Learning regarding the handover has been shared with the rest of the Trust. SaS handover is part of the Trust’s Safety and Security Procedure and an audit is planned for Q1 2020/21 to ensure that the wards are using the correct documentation and this is being completed appropriately.”

Source location

2020-0023-Response-from-Lancashire-and-South-Cumbria-NHS-Foundation-Trust-Redacted
Page 2 · response
Published 8 February 2020

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

Make clinical risk assessment training mandatory for all clinical staff delivering mental health services.

Verbatim wording from the response

“Trust Level: o Ward Managers Task & Finish Group established which includes looking at Policy and Practice. o Clinical risk assessment training - A practice note was sent out trust-wide on 31/01/2020 clarifying the training expectations of all mental health staff. Clinical risk training has now been made mandatory for all clinical staff delivering mental health services (attachment 11).”

Source location

2020-0023-Response-from-Lancashire-and-South-Cumbria-NHS-Foundation-Trust-Redacted
Page 3 · response
Published 8 February 2020

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 a rapid improvement event to review the Safety and Security role and revise documentation if required.

Verbatim wording from the response

“o A rapid improvement event to review the role and to revise documentation, if required, was due to be undertaken in March 2020 however this has been paused due to COVID 19; the new target date is July 2020.”

Source location

2020-0023-Response-from-Lancashire-and-South-Cumbria-NHS-Foundation-Trust-Redacted
Page 2 · response
Published 8 February 2020

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 supervision for the Ward Manager and Matron on AWOL procedures.

Verbatim wording from the response

“o The Head of Nursing has completed a supervision session with the Ward Manager and Matron.”

Source location

2020-0023-Response-from-Lancashire-and-South-Cumbria-NHS-Foundation-Trust-Redacted
Page 2 · response
Published 8 February 2020

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

Establish a Ward Managers Task and Finish Group addressing policy and practice.

Verbatim wording from the response

“Trust Level: o Ward Managers Task & Finish Group established which includes looking at Policy and Practice. o Clinical risk assessment training - A practice note was sent out trust-wide on 31/01/2020 clarifying the training expectations of all mental health staff. Clinical risk training has now been made mandatory for all clinical staff delivering mental health services (attachment 11).”

Source location

2020-0023-Response-from-Lancashire-and-South-Cumbria-NHS-Foundation-Trust-Redacted
Page 3 · response
Published 8 February 2020

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

Induct all new staff to Safety and Security procedures.

Verbatim wording from the response

“o All new staff are inducted to the SaS procedures (attachment 10)”

Source location

2020-0023-Response-from-Lancashire-and-South-Cumbria-NHS-Foundation-Trust-Redacted
Page 3 · response
Published 8 February 2020

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

Debrief staff involved in the care following learning from the inquest.

Verbatim wording from the response

“• A debrief with the staff involved in the care of Mr Clark following learning from the inquest on 12 February 2020 has been undertaken.”

Source location

2020-0023-Response-from-Lancashire-and-South-Cumbria-NHS-Foundation-Trust-Redacted
Page 3 · response
Published 8 February 2020

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 the action plan to incorporate additional views and oversee it through the Trust Quality Committee.

Verbatim wording from the response

“The Trust acknowledges that further work needed to be undertaken to the action plan to reflect the additional views of you and Mr Clark’s family. The strengthened action plan is attached. The Trust Quality Committee will oversee this action plan going forward.”

Source location

2020-0023-Response-from-Lancashire-and-South-Cumbria-NHS-Foundation-Trust-Redacted
Page 3 · response
Published 8 February 2020

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 agree an inpatient safety matrix audit tool covering Section 17 leave.

Verbatim wording from the response

“o Section 17 leave - An inpatient safety matrix which will audit this practice at ward level includes a section of Section 17 Leave. The audit tool has been developed and agreed with Ward Managers (attachment 4). However implementation has been paused due to COVID 19 (new target date September 2020) once implemented compliance will be reported on a monthly basis through the Senior Leadership Team.”

Source location

2020-0023-Response-from-Lancashire-and-South-Cumbria-NHS-Foundation-Trust-Redacted
Page 1 · response
Published 8 February 2020

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

Provide AWOL procedure training through inpatient development days and follow-up email communication.

Verbatim wording from the response

“o AWOL procedure has been discussed at the Orchard In-Patient Development days and followed up with email to ensure all staff understand new process (email re AWOL procedures, attachment 7).”

Source location

2020-0023-Response-from-Lancashire-and-South-Cumbria-NHS-Foundation-Trust-Redacted
Page 2 · response
Published 8 February 2020

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

Share Safety and Security handover learning across the Trust.

Verbatim wording from the response

“Trust Level: o Learning regarding the handover has been shared with the rest of the Trust. SaS handover is part of the Trust’s Safety and Security Procedure and an audit is planned for Q1 2020/21 to ensure that the wards are using the correct documentation and this is being completed appropriately.”

Source location

2020-0023-Response-from-Lancashire-and-South-Cumbria-NHS-Foundation-Trust-Redacted
Page 2 · response
Published 8 February 2020

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

Issue a practice note reminding relevant staff of accountability for Mental Health Act documentation and Trust policy.

Verbatim wording from the response

“o A practice note has been issued to Ward Managers, Lead Nurses and Doctors reminding them of their accountability in following MHA documentation and Trust policy (attachment 5).”

Source location

2020-0023-Response-from-Lancashire-and-South-Cumbria-NHS-Foundation-Trust-Redacted
Page 2 · response
Published 8 February 2020

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 the AWOL policy and procedure, including agreeing return times and initiating procedures when service users do not return.

Verbatim wording from the response

“Unit Level: o The Trust policy and procedure for AWOL has been updated and is in line with this staff agree with service users the time they will return from leave. If the service user has not returned by the agreed time AWOL procedures are implemented (SaS documentation, attachment 6).”

Source location

2020-0023-Response-from-Lancashire-and-South-Cumbria-NHS-Foundation-Trust-Redacted
Page 2 · response
Published 8 February 2020

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 detained-patient Mental Health Act documentation daily and distribute status reports to wards.

Verbatim wording from the response

“Trust Level o Monitoring and reporting of Mental Health Act documentation - The Mental Health Law Team monitor the status of all detained patients daily and send a daily status report to each ward for review. The report is sent to Responsible Clinicians, Matrons, Ward Mangers, Deputy Ward Managers, Nursing staff, Medical Secretaries, Pharmacy and any additional staff as appropriate (attachment 3).”

Source location

2020-0023-Response-from-Lancashire-and-South-Cumbria-NHS-Foundation-Trust-Redacted
Page 1 · response
Published 8 February 2020

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 pre- and post-leave assessment form in the RiO electronic care record across Secure Services.

Verbatim wording from the response

“o Work has been undertaken to the new electronic care record RiO which now includes a pre and post leave assessment form. This is in place in Secure Services and is to be rolled out across the Trust by March 2021.”

Source location

2020-0023-Response-from-Lancashire-and-South-Cumbria-NHS-Foundation-Trust-Redacted
Page 2 · response
Published 8 February 2020

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

Implementation of the Section 17 leave audit and Safety and Security role review was paused because of COVID-19.

Verbatim wording from the response

“o Section 17 leave - An inpatient safety matrix which will audit this practice at ward level includes a section of Section 17 Leave. The audit tool has been developed and agreed with Ward Managers (attachment 4). However implementation has been paused due to COVID 19 (new target date September 2020) once implemented compliance will be reported on a monthly basis through the Senior Leadership Team.”

Source location

2020-0023-Response-from-Lancashire-and-South-Cumbria-NHS-Foundation-Trust-Redacted
Page 1 · response
Published 8 February 2020

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