Henry Marsh · Prevention of Future Deaths report

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Issued 2 Jul 2014•North London

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.

View original report
Concerns
2

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
1

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 raised2

  1. Failure to hold effective multidisciplinary meetings
    Part of recurring concern: Unsafe operation of multidisciplinary clinical meetings
  2. Excessive Home Treatment Team caseloads

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. Department of Health and Social Care

    Map best-practice guidance onto the mental-health intelligence network during the next programme phase.

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

  1. Department of Health and Social Care

    Responsibility for resourcing Home Treatment Teams rests with local Clinical Commissioning Groups.

    Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking 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

Failure to hold effective multidisciplinary meetings

Wider context from the report

“The numbers of patients that the Home Treatment Team have under their care were too many and there were difficulties in holding effective multi – disciplinary meetings when carrying such a large caseload. ”

Is this part of a recurring concern?

Yes — Unsafe operation of multidisciplinary clinical meetings.

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

Excessive Home Treatment Team caseloads

Wider context from the report

“The numbers of patients that the Home Treatment Team have under their care were too many and there were difficulties in holding effective multi – disciplinary meetings when carrying such a large caseload. ”

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

Map best-practice guidance onto the mental-health intelligence network during the next programme phase.

Verbatim wording from the response

“NHS England intends to map this best practice guidance on to the mental health intelligence network in the next phase of its programme of work. There is currently no set timeline for this to take place. In the meantime, NHS England has put a summary of the guidance with relevant links on the Health and Wellbeing website: http://bit.ly/1rQN2UZ”

Source location

2014-0306-Response-by-Department-of-Health
Page 2 · response
Published 2 July 2014

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

Responsibility for resourcing Home Treatment Teams rests with local Clinical Commissioning Groups.

Verbatim wording from the response

“The inquest concluded that Mr Marsh committed suicide whilst under the care of the local Home Treatment Team. You are concerned that the team could not function effectively with its current caseload.”

Source location

2014-0306-Response-by-Department-of-Health
Page 1 · response
Published 2 July 2014

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