PFD report

Carolyne Senior · Prevention of Future Deaths report

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Issued 11 Nov 2020•South Yorkshire (Western)

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
2

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
6

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 account for patients’ mental health needs in falls risk assessments and mitigations
  2. Inadequate specialist mental health provision to support hospital staff caring for patients with mental health needs
    Part of recurring concern: Unreliable specialist mental health support in hospital care
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.5

  1. Action

    Update falls risk assessments and management plans to address mental-health needs and contact Mental Health Liaison where appropriate.

    Stated by Barnsley HospitalStated completedThe respondent said that this action was complete when they made their response on 23 December 2020.
  2. Action

    Inform nursing staff about the updated mental-health falls-risk assessment process through forums and monthly quality reporting.

    Stated by Barnsley HospitalStated in progressThe respondent said that this action was in progress when they made their response on 23 December 2020.
  3. Action

    Prepare and distribute a Trust-wide “Learning From” bulletin explaining the mental-health changes to falls-risk assessments.

    Stated by Barnsley HospitalStated plannedThe respondent said that this action was planned when they made their response on 23 December 2020.

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

  1. Position

    The mental health liaison service has recently received significant investment, achieved CORE 24 status, and provides support equivalent to other regional trusts.

    Stated by Barnsley HospitalDisputes 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 account for patients’ mental health needs in falls risk assessments and mitigations

Wider context from the report

“Evidence was given that Carolyne’s mental health issues could have inhibited her insight and ability to follow advice around falls prevention. The SI report author accepted in evidence that the question of whether hospital staff had sufficient access to advice to support them in caring for patients with mental health needs had not been addressed in that review. Nursing evidence was to the effect that advice and guidance was limited. In particular that mental health staff could take a very long time to attend a ward when asked but, more generally, that mental health input was insufficient to support hospital staff in caring for such patients and was known to be provided to a better standard in other hospitals. I was concerned that staff in Barnsley hospital did not take sufficient account of Carolyne’s mental health needs in formulating falls risk assessments and mitigations. I was concerned that there may be inadequate specialist provision to support staff in caring for patients with mental health needs such that these patients, some of whom may be challenging to care for, would therefore be placed at greater risk of falls than would be the case if risk assessments were formulated with their specific needs in mind. ”

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

Inadequate specialist mental health provision to support hospital staff caring for patients with mental health needs

Wider context from the report

“Evidence was given that Carolyne’s mental health issues could have inhibited her insight and ability to follow advice around falls prevention. The SI report author accepted in evidence that the question of whether hospital staff had sufficient access to advice to support them in caring for patients with mental health needs had not been addressed in that review. Nursing evidence was to the effect that advice and guidance was limited. In particular that mental health staff could take a very long time to attend a ward when asked but, more generally, that mental health input was insufficient to support hospital staff in caring for such patients and was known to be provided to a better standard in other hospitals. I was concerned that staff in Barnsley hospital did not take sufficient account of Carolyne’s mental health needs in formulating falls risk assessments and mitigations. I was concerned that there may be inadequate specialist provision to support staff in caring for patients with mental health needs such that these patients, some of whom may be challenging to care for, would therefore be placed at greater risk of falls than would be the case if risk assessments were formulated with their specific needs in mind. ”

Is this part of a recurring concern?

Yes — Unreliable specialist mental health support in hospital care.

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

Update falls risk assessments and management plans to address mental-health needs and contact Mental Health Liaison where appropriate.

Verbatim wording from the response

“Following receipt of the outcome at inquest, the executive nursing team have reviewed and updated the falls risk assessment process to include specific assessment of the patient’s mental health condition, and whether this impacts on their ability to retain information in an effort to reduce their risk of falling. In addition, the management plan has been updated to include a direct reference to an intervention to contact Mental Health Liaison (EXH 2 and 3) in both groups of patients (aged under 65 years of age and aged over 65 years of age).”

Source location

Response-from-Barnsley-Hospital-NHS-Foundation-Trust-Redacted.pdf
Page 3 · response
Published 23 December 2020

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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

Inform nursing staff about the updated mental-health falls-risk assessment process through forums and monthly quality reporting.

Verbatim wording from the response

“As the falls assessment process has been updated we are informing the nursing staff of this change at Senior Nurse Forum meeting, Falls Prevention Group, Falls Steering Group and this will also be included in the monthly nursing quality report. The patient Safety Team will also prepare a “Learning From” bulletin which will be sent to all employees of the Trust to explain the changes to our falls risk assessments in respect of mental health.”

Source location

Response-from-Barnsley-Hospital-NHS-Foundation-Trust-Redacted.pdf
Page 4 · response
Published 23 December 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

Prepare and distribute a Trust-wide “Learning From” bulletin explaining the mental-health changes to falls-risk assessments.

Verbatim wording from the response

“As the falls assessment process has been updated we are informing the nursing staff of this change at Senior Nurse Forum meeting, Falls Prevention Group, Falls Steering Group and this will also be included in the monthly nursing quality report. The patient Safety Team will also prepare a “Learning From” bulletin which will be sent to all employees of the Trust to explain the changes to our falls risk assessments in respect of mental health.”

Source location

Response-from-Barnsley-Hospital-NHS-Foundation-Trust-Redacted.pdf
Page 4 · response
Published 23 December 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

Add mental-health questions to the falls Root Cause Analysis document.

Verbatim wording from the response

“Since the inquest of Carolyne, the Trust has now included the following two questions in the Root Cause Analysis document:”

Source location

Response-from-Barnsley-Hospital-NHS-Foundation-Trust-Redacted.pdf
Page 2 · response
Published 23 December 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

Renew the Enhanced Care Policy to reflect the updated falls-risk interventions and obtain formal governance approval.

Verbatim wording from the response

“The assessments for both groups includes consideration of escalating the patient for enhanced care. The Trust has a policy (Enhanced Care Policy) to include the interventions as described in the falls risk assessment above (EXH 2 and 3). The policy is due for renewal in early 2021 and these elements will be reflected in that update. The Trust will provide you”

Source location

Response-from-Barnsley-Hospital-NHS-Foundation-Trust-Redacted.pdf
Page 3 · response
Published 23 December 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

The mental health liaison service has recently received significant investment, achieved CORE 24 status, and provides support equivalent to other regional trusts.

Verbatim wording from the response

“Mental Health Liaison Psychiatry Service are a service commissioned by Barnsley CCG. They are based in the Emergency Department and access into in-patient wards, and into which all of the hospital areas can contact and refer for advice. The service is delivered by South West Yorkshire Partnership Trust (SWYPT). Consultations with SWYPT have demonstrated that they have invested a significant amount of resources recently into the Mental Health Liaison Psychiatry service to achieve ‘CORE 24’ Status and to make the service ‘All-age’. This is the same level of mental health service support provided into each of the other South Yorkshire and Bassetlaw Integrated Care System Trusts (although Barnsley’s service is the only 'all-age' service).”

Source location

Response-from-Barnsley-Hospital-NHS-Foundation-Trust-Redacted.pdf
Page 2 · response
Published 23 December 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

Mental health liaison provision is commissioned by Barnsley CCG and delivered by South West Yorkshire Partnership Trust.

Verbatim wording from the response

“Mental Health Liaison Psychiatry Service are a service commissioned by Barnsley CCG. They are based in the Emergency Department and access into in-patient wards, and into which all of the hospital areas can contact and refer for advice. The service is delivered by South West Yorkshire Partnership Trust (SWYPT). Consultations with SWYPT have demonstrated that they have invested a significant amount of resources recently into the Mental Health Liaison Psychiatry service to achieve ‘CORE 24’ Status and to make the service ‘All-age’. This is the same level of mental health service support provided into each of the other South Yorkshire and Bassetlaw Integrated Care System Trusts (although Barnsley’s service is the only 'all-age' service).”

Source location

Response-from-Barnsley-Hospital-NHS-Foundation-Trust-Redacted.pdf
Page 2 · response
Published 23 December 2020

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

    Share learning from the case with the Mental Health Strategy Implementation Group.

    Stated by Barnsley HospitalStated completedThe respondent said that this action was complete when they made their response on 23 December 2020.

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 learning from the case with the Mental Health Strategy Implementation Group.

Verbatim wording from the response

“In 2019 the Trust launched its first Mental Health Strategy. The delivery of the strategy is undertaken by the Mental Health Strategy Implementation Group (MHSIG). The Trust is committed to improving the experience of staff and patients with a mental health condition at Barnsley Hospital. The learning from this case has been shared with the MHSIG.”

Source location

Response-from-Barnsley-Hospital-NHS-Foundation-Trust-Redacted.pdf
Page 4 · response
Published 23 December 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