PFD report

Jonathan Daniel Zucker · Prevention of Future Deaths report

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Issued 26 Jun 2017•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
1

Raised in this report

Recipients
2

Named on the report

Responses found
2

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 raised1

  1. Lack of a requirement or system for a lead clinician to oversee and coordinate mental health 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.2

  1. Action

    Place consultant accountability, transition ownership, and multi-team care issues on the Professional Practice and Ethics Committee agenda.

    Stated by Royal College of PsychiatristsStated plannedThe respondent said that this action was planned when they made their response on 26 June 2017.
  2. Action

    Decide the College’s next steps on consultant accountability, transition ownership, and care involving multiple teams.

    Stated by Royal College of PsychiatristsStated plannedThe respondent said that this action was planned when they made their response on 26 June 2017.

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

  1. Position

    The College has limited power to ensure patients have only one psychiatrist or responsible clinician.

    Stated by Royal College of PsychiatristsUnable 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 a requirement or system for a lead clinician to oversee and coordinate mental health care

Wider context from the report

“That there was no requirement for ,or system for, a lead clinician from either the private or NHS treating teams to oversee and coordinate the care provided to Mr Zucker by the private and NHS mental health services. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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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

Place consultant accountability, transition ownership, and multi-team care issues on the Professional Practice and Ethics Committee agenda.

Verbatim wording from the response

“Patients should only have one psychiatrist, and particularly only one responsible clinician. This is the best way to ensure good accountability, continuity of care and communication. Unfortunately, the College has limited power in this area, but will do what it can to address the problems outlined above. I have discussed this issue with our Dean, ████████, and we are both of the opinion that our Professional Practice and Ethics Committee are in the best position to take forward the College’s actions on these issues. The next meeting of the committee is on 2nd November 2017 and the specific issues of: consultant accountability; ownership during transitions; and care where more than one team is involved will be on the agenda and the college’s next steps will be decided.”

Source location

2017-0433-Response-by-PSYCH
Page 3 · response
Published 26 June 2017

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

Decide the College’s next steps on consultant accountability, transition ownership, and care involving multiple teams.

Verbatim wording from the response

“Patients should only have one psychiatrist, and particularly only one responsible clinician. This is the best way to ensure good accountability, continuity of care and communication. Unfortunately, the College has limited power in this area, but will do what it can to address the problems outlined above. I have discussed this issue with our Dean, ████████, and we are both of the opinion that our Professional Practice and Ethics Committee are in the best position to take forward the College’s actions on these issues. The next meeting of the committee is on 2nd November 2017 and the specific issues of: consultant accountability; ownership during transitions; and care where more than one team is involved will be on the agenda and the college’s next steps will be decided.”

Source location

2017-0433-Response-by-PSYCH
Page 3 · response
Published 26 June 2017

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 College has limited power to ensure patients have only one psychiatrist or responsible clinician.

Verbatim wording from the response

“Patients should only have one psychiatrist, and particularly only one responsible clinician. This is the best way to ensure good accountability, continuity of care and communication. Unfortunately, the College has limited power in this area, but will do what it can to address the problems outlined above. I have discussed this issue with our Dean, ████████, and we are both of the opinion that our Professional Practice and Ethics Committee are in the best position to take forward the College’s actions on these issues. The next meeting of the committee is on 2nd November 2017 and the specific issues of: consultant accountability; ownership during transitions; and care where more than one team is involved will be on the agenda and the college’s next steps will be decided.”

Source location

2017-0433-Response-by-PSYCH
Page 3 · response
Published 26 June 2017

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 Professional Practice and Ethics Committee is responsible for taking forward the College’s actions on accountability and care transitions.

Verbatim wording from the response

“Patients should only have one psychiatrist, and particularly only one responsible clinician. This is the best way to ensure good accountability, continuity of care and communication. Unfortunately, the College has limited power in this area, but will do what it can to address the problems outlined above. I have discussed this issue with our Dean, ████████, and we are both of the opinion that our Professional Practice and Ethics Committee are in the best position to take forward the College’s actions on these issues. The next meeting of the committee is on 2nd November 2017 and the specific issues of: consultant accountability; ownership during transitions; and care where more than one team is involved will be on the agenda and the college’s next steps will be decided.”

Source location

2017-0433-Response-by-PSYCH
Page 3 · response
Published 26 June 2017

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