PFD report

Henry Marsh · Prevention of Future Deaths report

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Issued 2 Jul 2014•North London

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
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

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 to hold effective multidisciplinary meetings
    Part of recurring concern: Unsafe operation of multidisciplinary clinical meetings
  2. Excessive Home Treatment Team caseloads
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

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

  1. Position

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

    Stated by Department of Health and Social CareRedirects 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 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

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

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

    Stated by Department of Health and Social CareStated plannedThe respondent said that this action was planned when they made their response on 2 July 2014.

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
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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