PFD report

Jonathan Anthony MEANEY · Prevention of Future Deaths report

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Issued 24 Aug 2017•Inner 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.

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Concerns
6

Raised in this report

Recipients
2

Named on the report

Responses found
2

Of 2 recipients

Stated actions
8

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 raised6

  1. Failure to reconcile and challenge contradictory suicide-risk information
    Part of recurring concern: Failure to reconcile conflicting information in safety assessmentsPart of recurring concern: Inadequate mental health risk assessmentPart of recurring concern: Unreliable assessment of suicide and self-harm risk
  2. Failure to recognise impaired insight in the context of recurrent unexplained physical symptoms
    Part of recurring concern: Unreliable assessment of patients’ mental state
  3. Failure to tailor discharge support to the patient’s reported lack of benefit from crisis-team care
    Part of recurring concern: Failure to provide timely and adequate follow-up after discharge
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.4

  1. Action

    Work closely with CANDI to assist its investigation, action-plan development and implementation to prevent similar incidents.

    Stated by Royal Free London NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 1 October 2017.
  2. Action

    Complete a serious incident review examining the sequence of events and contributory factors in the case.

    Stated by North London NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 1 October 2017.
  3. Action

    Write GPs an accompanying note identifying any specific action required of them when the mental health liaison team sends a referral or discharge summary.

    Stated by North London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 1 October 2017.

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

  1. Position

    CANDI, which employs and manages the Mental Health Liaison service, must substantively address the concerns.

    Stated by Royal Free London NHS Foundation TrustRedirects 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 reconcile and challenge contradictory suicide-risk information

Wider context from the report

“2. When the mental nurse assessed Mr Meaney before discharge on Wednesday, 15 March, he did not question Mr Meaney’s assertion that he had not intended to take an overdose two days before. This was despite the fact that Mr Meaney had told the assessing doctor that he had been trying to kill himself and he had written notes of intent. ”

Is this part of a recurring concern?

Yes — Failure to reconcile conflicting information in safety assessments; Inadequate mental health risk assessment; Unreliable assessment of suicide and self-harm risk.

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 recognise impaired insight in the context of recurrent unexplained physical symptoms

Wider context from the report

“3. The mental health nurse assessed Mr Meaney as rational and having good insight, despite the fact that Mr Meaney once again (as he had done repeatedly for many months) raised a physical problem for which no organic cause had been found. In court, the mental health nurse told me that he knew that Mr Meaney’s illness was mental rather than physical. ”

Is this part of a recurring concern?

Yes — Unreliable assessment of patients’ mental state.

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 tailor discharge support to the patient’s reported lack of benefit from crisis-team care

Wider context from the report

“5. The mental health nurse who saw Mr Meaney decided to refer Mr Meaney to his general practitioner for counselling, though Mr Meaney had already said that he had not found the crisis team helpful. Then having made that decision, I heard that there was no evidence that the mental health nurse did go on to make the referral. He told me that all he would do in such a situation would be to send the GP a discharge summary, never with a short accompanying note of request. ”

Is this part of a recurring concern?

Yes — Failure to provide timely and adequate follow-up after discharge.

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 provide timely and appropriately urgent access to a mental health bed

Wider context from the report

“1. Mr Meaney waited in the emergency unit for 40 hours and so it was unsurprising that he was then keen to go home. A mental health nurse from the C&I psychiatry liaison team called the bed manager on the morning of Tuesday, 14 March, and then saw Mr Meaney briefly to explain that no bed was available. The same nurse called the bed manager again the following morning, Wednesday, 15 March, and then saw Mr Meaney once again with no news about admission. It was at that point that Mr Meaney expressed a wish to leave. There seemed no urgency about the need for a bed for such a seriously ill man. ”

Is this part of a recurring concern?

Yes — Excessive waiting times for NHS mental health services; Insufficient psychiatric inpatient bed capacity.

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 complete and communicate general-practitioner referrals

Wider context from the report

“5. The mental health nurse who saw Mr Meaney decided to refer Mr Meaney to his general practitioner for counselling, though Mr Meaney had already said that he had not found the crisis team helpful. Then having made that decision, I heard that there was no evidence that the mental health nurse did go on to make the referral. He told me that all he would do in such a situation would be to send the GP a discharge summary, never with a short accompanying note of request. ”

Is this part of a recurring concern?

Yes — Unreliable mental health referral pathways.

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 obtain team consultation before mental health discharge clearance

Wider context from the report

“4. The mental health nurse did not consult any other member of the team before clearing Mr Meaney as fit for discharge from a mental health point of view. (The assessing doctor gave evidence that, if Mr Meaney had not agreed to admission to hospital when she saw him, she would have sought an assessment under the Mental Health Act with a view to detaining Mr Meaney for treatment.) ”

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

Work closely with CANDI to assist its investigation, action-plan development and implementation to prevent similar incidents.

Verbatim wording from the response

“It follows that the Matters of Concern will need to be addressed substantively by CANDI, which we note has received your Prevention of Future Deaths Report. We understand that CANDI are undertaking a Serious Incident investigation and we are committed to working closely with CANDI, as necessary, to assist them in completing this investigation, developing and implementing an action plan to prevent similar incidents in future and to otherwise assist them in preparing their response to your Prevention of Future Deaths Report. Additionally, we have asked to be provided with copies of CANDI’s final Serious Incident investigation report and response to your Prevention of Future Deaths Report, to ensure that any opportunities for learning within this Trust are captured and shared appropriately.”

Source location

2017-0244-Response
Page 1 · response
Published 1 October 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

Complete a serious incident review examining the sequence of events and contributory factors in the case.

Verbatim wording from the response

“We are undertaking a serious incident review of this case. Part of its scope is to undertake an in-depth analysis to ascertain in further detail exactly what steps were taken as Trust to secure Mr Meaney a bed. We will forward you our serious incident review on its completion. We are aiming to complete our review in November.”

Source location

2017-0244-Response2
Page 2 · response
Published 1 October 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

Write GPs an accompanying note identifying any specific action required of them when the mental health liaison team sends a referral or discharge summary.

Verbatim wording from the response

“Going forwards, if there is any specific action that we need a GP to carry out, the mental health liaison team will now write an accompanying note to alert the GP to the specific action and what they are required to do.”

Source location

2017-0244-Response2
Page 4 · response
Published 1 October 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

Require agency or bank staff changing another clinician’s decision to de-escalate an outcome to obtain senior agreement and record it in the patient’s notes.

Verbatim wording from the response

“- Any decision taken by agency or bank staff to change the original decision made by another full time clinician whereby they are de-escalating the outcome, must be discussed and agreed with a senior member of the team and this must be clearly recorded in the patients notes;”

Source location

2017-0244-Response2
Page 3 · response
Published 1 October 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

CANDI, which employs and manages the Mental Health Liaison service, must substantively address the concerns.

Verbatim wording from the response

“We have carefully considered the Matters of Concern, all of which relate to care that was delivered by the Camden & Islington NHS Foundation Trust’s Mental Health Liaison service, based within the Royal Free Hospital Emergency Department. The staff working within the Mental Health Liaison service are employed by the Camden & Islington NHS Foundation Trust (“CANDI”), not this Trust (the Royal Free London NHS Foundation Trust), and CANDI manage the Mental Health Liaison service. If a patient attending the Trust’s Emergency Department is considered to have a mental health problem (pertinent to the attendance) or requires a mental health assessment, they are referred to the Mental Health Liaison service, which will then assess the patient and take responsibility for referring onwards to either CANDI’s inpatient facilities or another mental health trust, as appropriate.”

Source location

2017-0244-Response
Page 1 · response
Published 1 October 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

Bed allocation urgency was assessed against clinical risk and safety, with priority given to patients not in places of safety.

Verbatim wording from the response

“The allocation of a bed is a centralised task, undertaken by the bed management team, managed by Camden and Islington NHS Foundation Trust. The bed management team received the referral from psychiatric liaison psychiatry, requesting a psychiatric bed for Mr Meaney at 04.46am on 14 March. Patients are prioritised according to both their clinical need, and the assessment of risk, for example, whether the patient is in a safe place. Patients who are not in places of safety i.e. at home or in police custody would take priority for acute beds. The referrals list is something that can change rapidly depending on the priority of the new referrals and whether the risk of an existing referral has changed. Senior staff meet daily to review all pending referrals and to estimate when a bed will become available.”

Source location

2017-0244-Response2
Page 2 · response
Published 1 October 2017

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.4

  1. 1

    Share the serious incident review learning with the relevant clinical team through the divisional quality forum.

    Stated by North London NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 1 October 2017.
  2. 2

    Suspend the agency nurse from working at that level of expertise until the serious incident review is completed.

    Stated by North London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 1 October 2017.
  3. 3

    Provide agency professionals who are settled team members with the same access to Trust training as Trust staff.

    Stated by North London NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 1 October 2017.
  4. 4

    Provide regular formal clinical supervision from the team manager to agency or bank staff who work regularly with the team.

    Stated by North London NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 1 October 2017.

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 the serious incident review learning with the relevant clinical team through the divisional quality forum.

Verbatim wording from the response

“- As referred to above, we are currently undertaking a serious incident review of this case so we can explore in further detail the sequence of events and contributory factors that led to this incident. The learning from the review will be shared within the relevant clinical team by the clinical director and lead investigator in our divisional quality forum where we discuss the learning arising from individual cases.”

Source location

2017-0244-Response2
Page 3 · response
Published 1 October 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

Suspend the agency nurse from working at that level of expertise until the serious incident review is completed.

Verbatim wording from the response

“- The nurse in question was an agency professional, employed by NHS Professionals (NHSP). In light of this case, he has been suspended from working at this level of expertise until the serious incident review has been completed. We have also shared your report with the HR department of NHSP and they are currently in contact with our liaison service manager who will keep them up to date with the findings of our serious incident review investigation;”

Source location

2017-0244-Response2
Page 3 · response
Published 1 October 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

Provide agency professionals who are settled team members with the same access to Trust training as Trust staff.

Verbatim wording from the response

“- Any agency professional working as settled members of the team will have the same access to Trust training as Trust staff.”

Source location

2017-0244-Response2
Page 3 · response
Published 1 October 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

Provide regular formal clinical supervision from the team manager to agency or bank staff who work regularly with the team.

Verbatim wording from the response

“- All agency or bank staff who work regularly with the team will receive regular formal clinical supervision from the team manager in line with Trust employees. This will ensure the same level of professional accountability and clinical support that all full time employees receive; and”

Source location

2017-0244-Response2
Page 3 · response
Published 1 October 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