Anthony Charles WALKER · Prevention of Future Deaths report

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Issued 14 May 2019•Portsmouth and South East Hampshire

Published report and response evidence

This report’s concerns and statements found in recipients’ published responses. Statements are included even where no link to an individual concern is recorded. A link shows an evidence connection; it does not assign responsibility.

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Concerns
0

Raised in this report

Recipients
4

Named on the report

Responses found
3

Of 4 recipients

Stated actions
21

Described in responses

Recipients and published responses

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 raised0

    Stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.21

    1. Portsmouth Hospitals University NHS Trust

      Continue discussions with SCAS about introducing real-time Emergency Department access to relevant 111 mental-health call information.

    2. Portsmouth Hospitals University NHS Trust

      Put in place a process giving the Mental Health Team direct telephone access to an Emergency Department consultant for advance notice of relevant attendances.

    3. Probation Service

      Support residents to register with the local Approved Premises GP within one week and record their consent for staff to contact the GP.

    4. Probation Service

      Link all Approved Premises with their Local Authority Suicide Prevention Action Plans.

    5. Probation Service

      Implement local Suicide Prevention Champions and a Divisional Champions Network across Approved Premises.

    6. Probation Service

      Require nominated Approved Premises or Area Managers to attend and contribute to the Divisional Suicide Prevention Forum.

    7. Probation Service

      Establish processes to communicate risk-to-self concerns to all Approved Premises staff.

    8. Probation Service

      Provide a distraction box at every Approved Premises for residents to access during crises or difficulties.

    9. Probation Service

      Require effective communication between Approved Premises staff and Offender Managers about residents’ risk-to-self information.

    10. Probation Service

      Provide ligature training for staff and make ligature knives available at Approved Premises.

    11. Probation Service

      Make suicide prevention and emotional wellbeing standing agenda items in specified Approved Premises staff, management and residents’ meetings.

    12. Probation Service

      Require each Approved Premises to identify a local Community Mental Health Team single point of contact to improve liaison.

    13. Probation Service

      Provide one-day First Aid training for staff with three-year refresher training.

    14. Probation Service

      Issue instructions requiring new residents to be asked and encouraged to sign consent forms enabling liaison with other agencies.

    15. Probation Service

      Provide suicide-prevention information on resident notice boards and Samaritans support cards in induction, crisis and departure materials.

    16. Probation Service

      Remind Approved Premises staff to support and facilitate referrals to agencies assisting residents’ care and management.

    17. Probation Service

      Remind Approved Premises staff to liaise with agencies involved in residents’ care.

    18. Probation Service

      Operate a national process for identifying, assessing, monitoring and managing residents who may pose a risk to self.

    19. Probation Service

      Maintain a collated file of local support information at each Approved Premises for staff to access and provide to residents.

    20. Probation Service

      Provide Self-Inflicted Harm/Deaths training for Approved Premises staff.

    21. South Central Ambulance Service NHS Foundation Trust

      Host Southern Health Foundation Trust mental health nurses in the Emergency Operations Centre 24 hours a day, seven days a week.

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

    1. Portsmouth Hospitals University NHS Trust

      Real-time access to 111 call contents is not currently feasible because of technical and resource constraints.

      Unable to actThe respondent said that a constraint prevented them from taking the relevant action.
    2. South Central Ambulance Service NHS Foundation Trust

      Portsmouth Hospital NHS Trust is assigned responsibility for liaising with Southern Health to identify and refer high-risk patient information to Queen Alexandra Hospital.

      Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
    3. South Central Ambulance Service NHS Foundation Trust

      Existing 24-hour mental health nurse assessment is considered an appropriate first response, reducing the need to send every 111 report to the Emergency Department.

      Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.

    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

    Continue discussions with SCAS about introducing real-time Emergency Department access to relevant 111 mental-health call information.

    Verbatim wording from the response

    “In response to the regulation 28 report, I can report that senior representatives from the Emergency Department have met with senior representatives from SCAS to discuss the feasibility of introducing a process to enable 111 calls to be made available for clinical staff in the Emergency Department (ED) to access in “real-time”. It was agreed that such a process would not currently be feasible for technical and resource reasons; however this is something that the 2 organisations will continue to discuss.”

    Source location

    2019-0152-Response-by-Portsmouth-Hospital-NHS-Trust
    Page 1 · response
    Published 28 July 2019

    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

    Put in place a process giving the Mental Health Team direct telephone access to an Emergency Department consultant for advance notice of relevant attendances.

    Verbatim wording from the response

    “Since Mr Walker’s death there have been changes within the SCAS Emergency Operations Centre in Otterbourne. I understand that a Mental Health Team (MHT) from Southern Health Foundation Trust is now hosted within the Ops Centre on a 24 hours a day, 7 days a week basis. As I understand it, patients who are identified by 111 callers as being at high risk of suicide or self-harm are referred onward to the MHT in the Ops Centre. It is possible that the SCAS hosted MHT may occasionally consider it appropriate to advise those patients to attend ED, because they also have a physical health need, and PHT are putting in place a process with SCAS to ensure that the MHT team have direct telephone access to a Consultant in ED to give them advanced notice of the attendance.”

    Source location

    2019-0152-Response-by-Portsmouth-Hospital-NHS-Trust
    Page 1 · response
    Published 28 July 2019

    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

    Support residents to register with the local Approved Premises GP within one week and record their consent for staff to contact the GP.

    Verbatim wording from the response

    “The NPS has now produced a National Reducing Self-Inflicted Harm/Deaths Action Plan requiring that all Approved Premises must:”

    Source location

    2019-0152-Response-by-NPS
    Page 2 · response
    Published 28 July 2019

    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

    Link all Approved Premises with their Local Authority Suicide Prevention Action Plans.

    Verbatim wording from the response

    “The NPS has now produced a National Reducing Self-Inflicted Harm/Deaths Action Plan requiring that all Approved Premises must:”

    Source location

    2019-0152-Response-by-NPS
    Page 2 · response
    Published 28 July 2019

    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

    Implement local Suicide Prevention Champions and a Divisional Champions Network across Approved Premises.

    Verbatim wording from the response

    “The NPS has now produced a National Reducing Self-Inflicted Harm/Deaths Action Plan requiring that all Approved Premises must:”

    Source location

    2019-0152-Response-by-NPS
    Page 2 · response
    Published 28 July 2019

    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 nominated Approved Premises or Area Managers to attend and contribute to the Divisional Suicide Prevention Forum.

    Verbatim wording from the response

    “The NPS has now produced a National Reducing Self-Inflicted Harm/Deaths Action Plan requiring that all Approved Premises must:”

    Source location

    2019-0152-Response-by-NPS
    Page 2 · response
    Published 28 July 2019

    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

    Establish processes to communicate risk-to-self concerns to all Approved Premises staff.

    Verbatim wording from the response

    “The NPS has now produced a National Reducing Self-Inflicted Harm/Deaths Action Plan requiring that all Approved Premises must:”

    Source location

    2019-0152-Response-by-NPS
    Page 2 · response
    Published 28 July 2019

    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 a distraction box at every Approved Premises for residents to access during crises or difficulties.

    Verbatim wording from the response

    “The NPS has now produced a National Reducing Self-Inflicted Harm/Deaths Action Plan requiring that all Approved Premises must:”

    Source location

    2019-0152-Response-by-NPS
    Page 2 · response
    Published 28 July 2019

    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 effective communication between Approved Premises staff and Offender Managers about residents’ risk-to-self information.

    Verbatim wording from the response

    “The NPS has now produced a National Reducing Self-Inflicted Harm/Deaths Action Plan requiring that all Approved Premises must:”

    Source location

    2019-0152-Response-by-NPS
    Page 2 · response
    Published 28 July 2019

    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 ligature training for staff and make ligature knives available at Approved Premises.

    Verbatim wording from the response

    “The NPS has now produced a National Reducing Self-Inflicted Harm/Deaths Action Plan requiring that all Approved Premises must:”

    Source location

    2019-0152-Response-by-NPS
    Page 2 · response
    Published 28 July 2019

    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

    Make suicide prevention and emotional wellbeing standing agenda items in specified Approved Premises staff, management and residents’ meetings.

    Verbatim wording from the response

    “The NPS has now produced a National Reducing Self-Inflicted Harm/Deaths Action Plan requiring that all Approved Premises must:”

    Source location

    2019-0152-Response-by-NPS
    Page 2 · response
    Published 28 July 2019

    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 each Approved Premises to identify a local Community Mental Health Team single point of contact to improve liaison.

    Verbatim wording from the response

    “In terms of future action, I will be issuing the following instructions to all Approved Premises across the SWSC Division.”

    Source location

    2019-0152-Response-by-NPS
    Page 1 · response
    Published 28 July 2019

    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 one-day First Aid training for staff with three-year refresher training.

    Verbatim wording from the response

    “The NPS has now produced a National Reducing Self-Inflicted Harm/Deaths Action Plan requiring that all Approved Premises must:”

    Source location

    2019-0152-Response-by-NPS
    Page 2 · response
    Published 28 July 2019

    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

    Issue instructions requiring new residents to be asked and encouraged to sign consent forms enabling liaison with other agencies.

    Verbatim wording from the response

    “In terms of future action, I will be issuing the following instructions to all Approved Premises across the SWSC Division.”

    Source location

    2019-0152-Response-by-NPS
    Page 1 · response
    Published 28 July 2019

    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 suicide-prevention information on resident notice boards and Samaritans support cards in induction, crisis and departure materials.

    Verbatim wording from the response

    “The NPS has now produced a National Reducing Self-Inflicted Harm/Deaths Action Plan requiring that all Approved Premises must:”

    Source location

    2019-0152-Response-by-NPS
    Page 2 · response
    Published 28 July 2019

    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

    Remind Approved Premises staff to support and facilitate referrals to agencies assisting residents’ care and management.

    Verbatim wording from the response

    “In terms of future action, I will be issuing the following instructions to all Approved Premises across the SWSC Division.”

    Source location

    2019-0152-Response-by-NPS
    Page 1 · response
    Published 28 July 2019

    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

    Remind Approved Premises staff to liaise with agencies involved in residents’ care.

    Verbatim wording from the response

    “In terms of future action, I will be issuing the following instructions to all Approved Premises across the SWSC Division.”

    Source location

    2019-0152-Response-by-NPS
    Page 1 · response
    Published 28 July 2019

    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 national process for identifying, assessing, monitoring and managing residents who may pose a risk to self.

    Verbatim wording from the response

    “The NPS has now produced a National Reducing Self-Inflicted Harm/Deaths Action Plan requiring that all Approved Premises must:”

    Source location

    2019-0152-Response-by-NPS
    Page 2 · response
    Published 28 July 2019

    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

    Maintain a collated file of local support information at each Approved Premises for staff to access and provide to residents.

    Verbatim wording from the response

    “The NPS has now produced a National Reducing Self-Inflicted Harm/Deaths Action Plan requiring that all Approved Premises must:”

    Source location

    2019-0152-Response-by-NPS
    Page 2 · response
    Published 28 July 2019

    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 Self-Inflicted Harm/Deaths training for Approved Premises staff.

    Verbatim wording from the response

    “The NPS has now produced a National Reducing Self-Inflicted Harm/Deaths Action Plan requiring that all Approved Premises must:”

    Source location

    2019-0152-Response-by-NPS
    Page 2 · response
    Published 28 July 2019

    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

    Host Southern Health Foundation Trust mental health nurses in the Emergency Operations Centre 24 hours a day, seven days a week.

    Verbatim wording from the response

    “Since Mr Walker’s death in November 2017, there have been changes within our Emergency Operations Centre in Otterbourne. We now host Mental Health Nurses from Southern Health Foundation Trust within our call centre 24 hours a day, 7 days a week. This is on a long-term trial basis until December 2019 and is funded by our local Commissioners, Hampshire County Council and the Police and Crime Commissioner. It is sensible for callers to be assessed by this service first so they can assess whether attendance at the Emergency Department is necessary. PHT will now liaise with ████████ from Southern Health to discuss how information regarding their assessment of patients identified as being at high risk of suicide or self-harm will be identified and”

    Source location

    2019-0152-Response-by-South-Central-Ambulance-Service-NHS-Trust
    Page 1 · response
    Published 28 July 2019

    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

    Real-time access to 111 call contents is not currently feasible because of technical and resource constraints.

    Verbatim wording from the response

    “In response to the regulation 28 report, I can report that senior representatives from the Emergency Department have met with senior representatives from SCAS to discuss the feasibility of introducing a process to enable 111 calls to be made available for clinical staff in the Emergency Department (ED) to access in “real-time”. It was agreed that such a process would not currently be feasible for technical and resource reasons; however this is something that the 2 organisations will continue to discuss.”

    Source location

    2019-0152-Response-by-Portsmouth-Hospital-NHS-Trust
    Page 1 · response
    Published 28 July 2019

    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

    Portsmouth Hospital NHS Trust is assigned responsibility for liaising with Southern Health to identify and refer high-risk patient information to Queen Alexandra Hospital.

    Verbatim wording from the response

    “Since Mr Walker’s death in November 2017, there have been changes within our Emergency Operations Centre in Otterbourne. We now host Mental Health Nurses from Southern Health Foundation Trust within our call centre 24 hours a day, 7 days a week. This is on a long-term trial basis until December 2019 and is funded by our local Commissioners, Hampshire County Council and the Police and Crime Commissioner. It is sensible for callers to be assessed by this service first so they can assess whether attendance at the Emergency Department is necessary. PHT will now liaise with ████████ from Southern Health to discuss how information regarding their assessment of patients identified as being at high risk of suicide or self-harm will be identified and”

    Source location

    2019-0152-Response-by-South-Central-Ambulance-Service-NHS-Trust
    Page 1 · response
    Published 28 July 2019

    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

    Existing 24-hour mental health nurse assessment is considered an appropriate first response, reducing the need to send every 111 report to the Emergency Department.

    Verbatim wording from the response

    “Since Mr Walker’s death in November 2017, there have been changes within our Emergency Operations Centre in Otterbourne. We now host Mental Health Nurses from Southern Health Foundation Trust within our call centre 24 hours a day, 7 days a week. This is on a long-term trial basis until December 2019 and is funded by our local Commissioners, Hampshire County Council and the Police and Crime Commissioner. It is sensible for callers to be assessed by this service first so they can assess whether attendance at the Emergency Department is necessary. PHT will now liaise with ████████ from Southern Health to discuss how information regarding their assessment of patients identified as being at high risk of suicide or self-harm will be identified and”

    Source location

    2019-0152-Response-by-South-Central-Ambulance-Service-NHS-Trust
    Page 1 · response
    Published 28 July 2019

    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