PFD report

Amanda Hawkins · Prevention of Future Deaths report

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Issued 26 Nov 2014•Staffordshire South

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
4

Raised in this report

Recipients
2

Named on the report

Responses found
1

Of 2 recipients

Stated actions
2

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 raised4

  1. Failure to contact healthcare professionals during missing-person risk assessment
    Part of recurring concern: Unreliable missing-person response
  2. Failure to direct hospital appointment correspondence to a person able to manage it
  3. Failure to maintain adequate support during moves, funding changes and step-down of services
    Part of recurring concern: Failure to maintain safe care and support during service transitions
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

    Copy North CRS outpatient letters to care coordinators.

    Stated by Dudley Integrated Health and Care NHS TrustStated completedThe respondent said that this action was complete when they made their response on 26 November 2014.
  2. Action

    Operate a Working Group led by the Head of Recovery Services to develop long-term solutions for missed-appointment follow-up.

    Stated by Dudley Integrated Health and Care NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 26 November 2014.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.3

  1. Position

    Copies of outpatient letters to placement providers are subject to existing consent and information-sharing policies.

    Stated by Dudley Integrated Health and Care NHS TrustUnable 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

Failure to contact healthcare professionals during missing-person risk assessment

Wider context from the report

“(1) When Amanda was reported missing she was classified as medium risk. No contact was made with her healthcare professionals. Had such contact been made earlier in the enquiry her risk profile may well have changed to high risk at an earlier point. This in turn may have led to a different approach in the search for her. ”

Is this part of a recurring concern?

Yes — Unreliable missing-person response.

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 direct hospital appointment correspondence to a person able to manage it

Wider context from the report

“(2) Hospital appointments were sent to Amanda at her home address when she did not have sufficient understanding to deal with correspondence. Care co-ordination workers were not made aware of missed appointments and there was therefore no follow up. Lack of follow up for essential appointments led to her increased vulnerability. ”

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 maintain adequate support during moves, funding changes and step-down of services

Wider context from the report

“(1) The moves following closure of various homes or changes in funding and step down in-services offered to Amanda resulted in her increased vulnerability. ”

Is this part of a recurring concern?

Yes — Failure to maintain safe care and support during service transitions.

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 identify missed essential appointments and provide follow-up

Wider context from the report

“(2) Hospital appointments were sent to Amanda at her home address when she did not have sufficient understanding to deal with correspondence. Care co-ordination workers were not made aware of missed appointments and there was therefore no follow up. Lack of follow up for essential appointments led to her increased vulnerability. ”

Is this part of a recurring concern?

Yes — Failure of case monitoring to identify cases requiring follow-up.

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

Copy North CRS outpatient letters to care coordinators.

Verbatim wording from the response

“The Trust utilises the Oasis electronic system which logs and records appointments and instances when patients fail to attend. The Trust does however acknowledge that letters from North Community Recovery Service (CRS) medical teams were not copied to the care coordinator or placement provider for them to be aware of the appointments that Miss Hawkins did not attend and therefore no subsequent follow up was made. This is acknowledged as an area of improvement for the Trust which will be managed through the Trust’s embedding lessons processes. Therefore, going forward within CRS North outpatient letters are now copied to the care coordinator and, in addition to this, the Trust has convened a Working Group to look at long term solutions to this issue; this Working Group is being led by the Trusts Head of Recovery Services.”

Source location

2014-0516-Response-by-Dudley-Walsall-NHS-Trust
Page 3 · response
Published 26 November 2014

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

Operate a Working Group led by the Head of Recovery Services to develop long-term solutions for missed-appointment follow-up.

Verbatim wording from the response

“The Trust utilises the Oasis electronic system which logs and records appointments and instances when patients fail to attend. The Trust does however acknowledge that letters from North Community Recovery Service (CRS) medical teams were not copied to the care coordinator or placement provider for them to be aware of the appointments that Miss Hawkins did not attend and therefore no subsequent follow up was made. This is acknowledged as an area of improvement for the Trust which will be managed through the Trust’s embedding lessons processes. Therefore, going forward within CRS North outpatient letters are now copied to the care coordinator and, in addition to this, the Trust has convened a Working Group to look at long term solutions to this issue; this Working Group is being led by the Trusts Head of Recovery Services.”

Source location

2014-0516-Response-by-Dudley-Walsall-NHS-Trust
Page 3 · response
Published 26 November 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

Copies of outpatient letters to placement providers are subject to existing consent and information-sharing policies.

Verbatim wording from the response

“Where appropriate, consideration will also be given to copies of such letters being sent to placement providers, however this would need to be done in line with existing policies regarding consent and the sharing of information.”

Source location

2014-0516-Response-by-Dudley-Walsall-NHS-Trust
Page 3 · response
Published 26 November 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

The panel responsible for the funded care package, rather than the Trust, is responsible for developing risk assessments for prolonged absences from placements.

Verbatim wording from the response

“It is the Trust’s view that in cases where there is a history of patients spending a prolonged time out of the placement they reside in, it will be the responsibility of the panel responsible for the allocated funded package of care to develop a risk assessment. The risk assessment would aim to identify how the risk of the patient not returning to the placement could be mitigated and identify what further support can be provided to the patient to enable effective engagement with the community services in a safer and more supportive manner.”

Source location

2014-0516-Response-by-Dudley-Walsall-NHS-Trust
Page 2 · response
Published 26 November 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

The step-down placement was clinically appropriate because Miss Hawkins was assessed as able to maintain her safety without further assistance.

Verbatim wording from the response

“The investigation/review highlighted that at the time of her placement it was appropriate for Miss Hawkins to reside at Moxley Court as it was felt that the step down in placement was clinically appropriate for Miss Hawkins. She had previously had a consistent care team (from CRS South) with who she generally engaged well with. The clinical appropriateness of this step down is further supported by the fact that Miss Hawkins was assessed as being able to maintain her own safety in the community without the need for further assistance in this regard.”

Source location

2014-0516-Response-by-Dudley-Walsall-NHS-Trust
Page 2 · response
Published 26 November 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