PFD report

Mr William Anthony Grieve · Prevention of Future Deaths report

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Issued 19 Mar 2025•Staffordshire and Stoke-on-Trent

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
3

Raised in this report

Recipients
3

Named on the report

Responses found
2

Of 3 recipients

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 raised3

  1. Lack of access to other teams’ electronic notes during suicide risk assessments
    Part of recurring concern: Unreliable inter-agency information sharing for coordinated care
  2. Failure to conduct risk assessments properly
  3. Failure to address staff training needs
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

    Implement a new process for assessing and documenting patient risk without risk stratification.

    Stated by Midlands Partnership University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 26 March 2025.
  2. Action

    Train all Talking Therapies staff on the new risk-assessment and documentation processes and provide a supporting resource pack.

    Stated by Midlands Partnership University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 26 March 2025.
  3. Action

    Conduct monthly audits from July 2025 to check compliance with the new risk processes and identify further training needs.

    Stated by Midlands Partnership University NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 26 March 2025.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.4

  1. Position

    Urgent or serious risks should be escalated immediately to secondary care under existing national Talking Therapies guidance rather than through shared record access.

    Stated by Midlands Partnership University NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.

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 access to other teams’ electronic notes during suicide risk assessments

Wider context from the report

“2. Both assessments, were incorrect, and took account of incorrect information because neither had access to the others computer system. Stoke Talking Therapies used IAPTUS and Crisis resolution used Lorenzo. There was no way for either team to see the others electronic notes. ”

Is this part of a recurring concern?

Yes — Unreliable inter-agency information sharing for coordinated care.

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 conduct risk assessments properly

Wider context from the report

“3. It was said in evidence, that a member of staff had not carried out a risk assessment properly whoever, nothing had been done to address this and there were no plans to address this. The concern being that staff training needs are not being addressed. ”

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 address staff training needs

Wider context from the report

“3. It was said in evidence, that a member of staff had not carried out a risk assessment properly whoever, nothing had been done to address this and there were no plans to address this. The concern being that staff training needs are not being addressed. ”

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

Implement a new process for assessing and documenting patient risk without risk stratification.

Verbatim wording from the response

“As a service, Staffordshire and Stoke on Trent Talking Therapies introduced a new process of assessing and documenting risk which came into force on 1 May 2025.”

Source location

Response from Midlands Partnership University NHS Foundation Trust
Page 3 · response
Published 26 March 2025

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

Train all Talking Therapies staff on the new risk-assessment and documentation processes and provide a supporting resource pack.

Verbatim wording from the response

“All staff working in the service received training on the new processes in April 2025. The training comprised of a live training session which was recorded for staff who were absent to watch at their earliest opportunity. A resource pack was also provided to all staff outlining in writing the new processes and requirements for assessing risk and writing this in notes.”

Source location

Response from Midlands Partnership University NHS Foundation Trust
Page 3 · response
Published 26 March 2025

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

Conduct monthly audits from July 2025 to check compliance with the new risk processes and identify further training needs.

Verbatim wording from the response

“Following implementation, a robust auditing process will be taking place monthly from July 2025 to ensure compliance and address any further staff training needs.”

Source location

Response from Midlands Partnership University NHS Foundation Trust
Page 3 · response
Published 26 March 2025

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

Initiate discussions with MPFT information governance and digital teams to include Talking Therapies data in the Integrated Care Record and agree the proposed dataset.

Verbatim wording from the response

“An Integrated Care Record (ICR) – already exists and NSCHT, MPFT, UHNМ and GP services each extracts an agreed dataset of information to this ICR system and NSCHT aim to take forward discussions with MPFT to do the same from IAPTUS electronic patient record to mitigate some of the system issues raised.”

Source location

Response from North Staffordshire Combined Healthcare NHS Trust
Page 3 · response
Published 26 March 2025

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 agreed cross-service checks and contact processes to identify patients using other mental health services, share relevant information, and incorporate it into risk assessment and review.

Verbatim wording from the response

“2. Assurance in the interim NSCHT plan to:”

Source location

Response from North Staffordshire Combined Healthcare NHS Trust
Page 4 · response
Published 26 March 2025

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

Urgent or serious risks should be escalated immediately to secondary care under existing national Talking Therapies guidance rather than through shared record access.

Verbatim wording from the response

“6. Nationally, it is not usual practice that secondary care staff have access to the Talking Therapies record system for the clinical and cost reasons outlined above. If urgent or serious risk presents in Talking Therapies services, it is standard and expected practice that these risks should be escalated to secondary care within the system immediately as per Talking Therapies national guidance, due to there being no medical staff in the team to advise on this.”

Source location

Response from Midlands Partnership University NHS Foundation Trust
Page 3 · response
Published 26 March 2025

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

NSCHT is responsible for providing and overseeing Talking Therapies in Stoke, including mandatory training for the locality team.

Verbatim wording from the response

“MPFT holds the contract for Talking Therapies in Staffordshire and Stoke on Trent, and sub-contracts to other partners. There are 7 different organisations who sub-contract from MPFT, NSCHT are one such provider. NSCHT provide the Talking Therapies services in Stoke, who I understand provided treatment to Mr Grieve.”

Source location

Response from Midlands Partnership University NHS Foundation Trust
Page 1 · response
Published 26 March 2025

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

Widening IAPTUS access is not currently considered feasible because of confidentiality, consent, supervision-note, system and data-protection constraints.

Verbatim wording from the response

“1. Talking Therapies in Staffordshire and Stoke on Trent treat a large number of NHS staff for therapy. They have been consented that their notes will remain confidential from other NHS services unless there are issues of risk or safeguarding, to assure them that their colleagues will not be able to view those psychological therapy notes. To open this access to IAPTUS and other NHS Staff poses a risks of breaches of confidentiality and a risk that staff will no longer come forward to access the service.”

Source location

Response from Midlands Partnership University NHS Foundation Trust
Page 2 · response
Published 26 March 2025

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

IAPTUS access cannot be widened because confidentiality, consent, supervision-note access, data-protection and system-design constraints prevent sharing full records.

Verbatim wording from the response

“i. Talking Therapies in Staffordshire and Stoke on Trent treat a large number of NHS staff for therapy. They have been consented that their notes will remain confidential from other NHS services unless there are issues of risk or safeguarding, to assure them that their colleagues will not be able to view those psychological therapy notes. To open this access to IAPTUS and other NHS Staff poses a risks of breaches of confidentiality and a risk that staff will no longer come forward to access the service.”

Source location

Response from North Staffordshire Combined Healthcare NHS Trust
Page 2 · response
Published 26 March 2025

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

    Review and revise the CRHTT procedure for managing non-attendance and ineffective contacts through Trust governance approval.

    Stated by North Staffordshire Combined Healthcare NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 26 March 2025.

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

Review and revise the CRHTT procedure for managing non-attendance and ineffective contacts through Trust governance approval.

Verbatim wording from the response

“(3) This evidence was in relation to a member of staff within the Crisis Resolution Home Treatment Team (CRHTT), not Talking Therapies. Upon further review, risk assessments were completed for Mr Grieve. Early organisational learning has led to a review of the standard operational procedure for service users who do not attend appointments the principles of this being adopted immediately whilst awaiting Trust governance approval processes.”

Source location

Response from North Staffordshire Combined Healthcare NHS Trust
Page 3 · response
Published 26 March 2025

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