PFD report

Marnie Emma Hill · Prevention of Future Deaths report

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Issued 17 Oct 2023•Dorset

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
5

Raised in this report

Recipients
1

Named on the report

Responses found
3

Of 1 recipient

Stated actions
11

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 raised5

  1. Lack of rules governing counsellors’ operation and record keeping
  2. Lack of requirements for counsellors to inform medical professionals or other appropriate support providers
    Part of recurring concern: Unreliable inter-agency information sharing for coordinated care
  3. Lack of regulation and licensing of the counselling profession
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

    Conduct a public consultation on criteria for deciding when statutory regulation of healthcare professions is appropriate.

    Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 30 October 2023.
  2. Action

    Keep professions subject to statutory regulation under review to assess whether regulatory oversight remains proportionate to public risk.

    Stated by Department of Health and Social CareStated in progressThe respondent said that this action was in progress when they made their response on 30 October 2023.

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

  1. Position

    Training standards and practice requirements set by independent counselling organisations are outside Government oversight.

    Stated by Department of Health and Social CareOutside remitThe respondent said that this matter was outside its role or authority.

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 rules governing counsellors’ operation and record keeping

Wider context from the report

“1. During the inquest evidence was heard that: i. There is no regulation of counsellors in England and Wales and this could lead to future deaths. ii. ████████ is a private counsellor with 30 years’ experience who provided support to Marnie prior to her death. She confirmed that counselling is not a regulated professional and there are courses available at a cost of £29 for a 6 week course, after which a person can receive a diploma and call themselves a counsellor. There is no requirement for them to do further training or continual professional development. There are no rules or regulations about how counsellors should operate, for example how they keep and share records. iii. Information shared by an individual to a counsellor may disclose a risk of self harm or suicide, or harm to another and there is no requirement for a counsellor to report that information to any third party. iv. ████████ ████████ gave evidence that the lack of regulation and licensing of counsellors could lead to a lot of damage being done to individuals seeking help and that this could present a risk to life as there is no regulation around informing medical professionals or others who can provided further support and care to the individual. v. Evidence was also given by ████████, one of the GPs who provided care to Marnie, that receipt of records from others such as counsellors, especially at the end of the counselling, would assist her in providing care to patients. 2. I have concerns with regard to the following: i. There is a risk of future deaths occurring due to the lack of regulation of the counselling profession. ”

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

Lack of requirements for counsellors to inform medical professionals or other appropriate support providers

Wider context from the report

“1. During the inquest evidence was heard that: i. There is no regulation of counsellors in England and Wales and this could lead to future deaths. ii. ████████ is a private counsellor with 30 years’ experience who provided support to Marnie prior to her death. She confirmed that counselling is not a regulated professional and there are courses available at a cost of £29 for a 6 week course, after which a person can receive a diploma and call themselves a counsellor. There is no requirement for them to do further training or continual professional development. There are no rules or regulations about how counsellors should operate, for example how they keep and share records. iii. Information shared by an individual to a counsellor may disclose a risk of self harm or suicide, or harm to another and there is no requirement for a counsellor to report that information to any third party. iv. ████████ ████████ gave evidence that the lack of regulation and licensing of counsellors could lead to a lot of damage being done to individuals seeking help and that this could present a risk to life as there is no regulation around informing medical professionals or others who can provided further support and care to the individual. v. Evidence was also given by ████████, one of the GPs who provided care to Marnie, that receipt of records from others such as counsellors, especially at the end of the counselling, would assist her in providing care to patients. 2. I have concerns with regard to the following: i. There is a risk of future deaths occurring due to the lack of regulation of the counselling profession. ”

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

Lack of regulation and licensing of the counselling profession

Wider context from the report

“1. During the inquest evidence was heard that: i. There is no regulation of counsellors in England and Wales and this could lead to future deaths. ii. ████████ is a private counsellor with 30 years’ experience who provided support to Marnie prior to her death. She confirmed that counselling is not a regulated professional and there are courses available at a cost of £29 for a 6 week course, after which a person can receive a diploma and call themselves a counsellor. There is no requirement for them to do further training or continual professional development. There are no rules or regulations about how counsellors should operate, for example how they keep and share records. iii. Information shared by an individual to a counsellor may disclose a risk of self harm or suicide, or harm to another and there is no requirement for a counsellor to report that information to any third party. iv. ████████ ████████ gave evidence that the lack of regulation and licensing of counsellors could lead to a lot of damage being done to individuals seeking help and that this could present a risk to life as there is no regulation around informing medical professionals or others who can provided further support and care to the individual. v. Evidence was also given by ████████, one of the GPs who provided care to Marnie, that receipt of records from others such as counsellors, especially at the end of the counselling, would assist her in providing care to patients. 2. I have concerns with regard to the following: i. There is a risk of future deaths occurring due to the lack of regulation of the counselling profession. ”

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

Lack of requirements for counsellors to report disclosed risks of self-harm, suicide or harm to others

Wider context from the report

“1. During the inquest evidence was heard that: i. There is no regulation of counsellors in England and Wales and this could lead to future deaths. ii. ████████ is a private counsellor with 30 years’ experience who provided support to Marnie prior to her death. She confirmed that counselling is not a regulated professional and there are courses available at a cost of £29 for a 6 week course, after which a person can receive a diploma and call themselves a counsellor. There is no requirement for them to do further training or continual professional development. There are no rules or regulations about how counsellors should operate, for example how they keep and share records. iii. Information shared by an individual to a counsellor may disclose a risk of self harm or suicide, or harm to another and there is no requirement for a counsellor to report that information to any third party. iv. ████████ ████████ gave evidence that the lack of regulation and licensing of counsellors could lead to a lot of damage being done to individuals seeking help and that this could present a risk to life as there is no regulation around informing medical professionals or others who can provided further support and care to the individual. v. Evidence was also given by ████████, one of the GPs who provided care to Marnie, that receipt of records from others such as counsellors, especially at the end of the counselling, would assist her in providing care to patients. 2. I have concerns with regard to the following: i. There is a risk of future deaths occurring due to the lack of regulation of the counselling profession. ”

Is this part of a recurring concern?

Yes — Failure to reliably report self-harm and suicide risks to people able to help.

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

Lack of requirements for counsellors’ further training and continual professional development

Wider context from the report

“1. During the inquest evidence was heard that: i. There is no regulation of counsellors in England and Wales and this could lead to future deaths. ii. ████████ is a private counsellor with 30 years’ experience who provided support to Marnie prior to her death. She confirmed that counselling is not a regulated professional and there are courses available at a cost of £29 for a 6 week course, after which a person can receive a diploma and call themselves a counsellor. There is no requirement for them to do further training or continual professional development. There are no rules or regulations about how counsellors should operate, for example how they keep and share records. iii. Information shared by an individual to a counsellor may disclose a risk of self harm or suicide, or harm to another and there is no requirement for a counsellor to report that information to any third party. iv. ████████ ████████ gave evidence that the lack of regulation and licensing of counsellors could lead to a lot of damage being done to individuals seeking help and that this could present a risk to life as there is no regulation around informing medical professionals or others who can provided further support and care to the individual. v. Evidence was also given by ████████, one of the GPs who provided care to Marnie, that receipt of records from others such as counsellors, especially at the end of the counselling, would assist her in providing care to patients. 2. I have concerns with regard to the following: i. There is a risk of future deaths occurring due to the lack of regulation of the counselling profession. ”

Is this part of a recurring concern?

Yes — Inadequate training and continuing-development requirements for unregulated healthcare practitioners.

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

Conduct a public consultation on criteria for deciding when statutory regulation of healthcare professions is appropriate.

Verbatim wording from the response

“Between 6 January 2022 and 31 March 2022 the Department of Health and Social Care, on behalf of the UK Government and the devolved administrations, ran a public consultation seeking views on the criteria for determining when statutory regulation of a healthcare profession is appropriate. Further information about this consultation is available at: https://www.gov.uk/government/consultations/healthcare-regulation-deciding-when-statutory-regulation-is-appropriate”

Source location

Response from Department of Health and Social Care
Page 2 · response
Published 30 October 2023

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

Keep professions subject to statutory regulation under review to assess whether regulatory oversight remains proportionate to public risk.

Verbatim wording from the response

“The Government keeps the professions subject to statutory regulation under review. Bringing a profession into statutory regulation is a lengthy and costly legal process. It is restrictive by its very nature and can act as a barrier to entry and inhibit the flexibility of a profession to grow and develop to meet patient needs. Other important considerations that need to be addressed before bringing a profession into regulation including the impact on the profession, which body should regulate and the geographical extent of regulation across the UK. Failure to undertake this work before legislating to regulate a profession could lead to unintended consequences that run counter to public protection.”

Source location

Response from Department of Health and Social Care
Page 2 · response
Published 30 October 2023

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

Training standards and practice requirements set by independent counselling organisations are outside Government oversight.

Verbatim wording from the response

“All of the organisations utilising the SCoPEd framework are independent, representative bodies for the practice of counselling and psychotherapy. As such, they do not fall under Government oversight and therefore any decisions about the training standards and practice requirements for the professions they represent are a matter for those organisations and their members.”

Source location

Response from Department of Health and Social Care
Page 3 · response
Published 30 October 2023

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 safeguards, including accredited voluntary registers and employer checks, support patient safety for people using counselling services.

Verbatim wording from the response

“People should be able to expect good quality psychotherapy or counselling services, which bring about a positive impact on their mental health and recovery. Although counsellors are not subject to statutory regulation, there are other safeguards in place to support patient safety for people using counselling services.”

Source location

Response from Department of Health and Social Care
Page 2 · response
Published 30 October 2023

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

There is no immediate case to change which professions are subject to statutory regulation.

Verbatim wording from the response

“While we believe that there is no immediate case to change the groups that are regulated, the consultation asked for views on how the powers to introduce and remove professions from regulation might be used in the future and:”

Source location

Response from Department of Health and Social Care
Page 2 · response
Published 30 October 2023

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

Independent counselling organisations and their members are responsible for decisions about training standards and practice requirements.

Verbatim wording from the response

“All of the organisations utilising the SCoPEd framework are independent, representative bodies for the practice of counselling and psychotherapy. As such, they do not fall under Government oversight and therefore any decisions about the training standards and practice requirements for the professions they represent are a matter for those organisations and their members.”

Source location

Response from Department of Health and Social Care
Page 3 · response
Published 30 October 2023

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.9

  1. 1

    Continue exploring partnership in the SWASFT Mental Health Desk service to maximise its benefits for Dorset residents.

    Stated by NHS Dorset Integrated Care BoardStated in progressThe respondent said that this action was in progress when they made their response on 30 October 2023.
  2. 2

    Develop a trusted assessor model with Dorset HealthCare, SWASFT and Dorset Police to improve operational coordination when supporting people in mental health crisis.

    Stated by NHS Dorset Integrated Care BoardStated in progressThe respondent said that this action was in progress when they made their response on 30 October 2023.
  3. 3

    Review and update Business Continuity Plans to assess adopting Scribe ECS as a secondary fallback system.

    Stated by South Western Ambulance Service NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 30 October 2023.
  4. 4

    Introduce a process and document-sharing system giving PAPs access to updated policies when released.

    Stated by South Western Ambulance Service NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 30 October 2023.
  5. 5

    Ensure PAP information is included in Clinical Leads’ Local Clinical Update documents available through the Clinical App.

    Stated by South Western Ambulance Service NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 30 October 2023.
  6. 6

    Reintroduce the Electronic Care System for operational use.

    Stated by South Western Ambulance Service NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 30 October 2023.
  7. 7

    Remind PAP contract leads of GP referral requirements and require dissemination and acknowledgement from their staff.

    Stated by South Western Ambulance Service NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 30 October 2023.
  8. 8

    Set up SWASFT Clinical App accounts for St John Ambulance staff supporting the Trust.

    Stated by South Western Ambulance Service NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 30 October 2023.
  9. 9

    Publish the Government’s response to the consultation on statutory healthcare-profession regulation.

    Stated by Department of Health and Social CareStated plannedThe respondent said that this action was planned when they made their response on 30 October 2023.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.2

  1. 1

    Dorset residents are not left without 24/7 mental-health support because local crisis services provide continuous support and advice.

    Stated by NHS Dorset Integrated Care BoardDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
  2. 2

    Existing local Access Mental Health services are considered sufficient to provide Dorset residents with 24/7 mental-health support without the SWASFT help desk.

    Stated by NHS Dorset Integrated Care BoardExisting 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 exploring partnership in the SWASFT Mental Health Desk service to maximise its benefits for Dorset residents.

Verbatim wording from the response

“We note that SWASFT have reported that without the 24/7 help desk people in Dorset are left without MH support that is 24/7; this is not the case. Whilst discussions are ongoing in relation to how we might maximise the benefits for Dorset residents by being partners in the SWASFT MH Desk 24/7, Dorset residents do in fact have access to 24/7 MH support and advice as set out above.”

Source location

Response from Dorset Integrated Care Board
Page 2 · response
Published 30 October 2023

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

Develop a trusted assessor model with Dorset HealthCare, SWASFT and Dorset Police to improve operational coordination when supporting people in mental health crisis.

Verbatim wording from the response

“Access Mental Health provides a crisis offer that was fully coproduced with many partners and stakeholders including SWASFT. However, we recognise there are still some challenges relating to referring patients between services and that there are not operating as consistently as we would like; to re-assure, these issues are being actively discussed including, as set out below, how we might further enhance this through our approach to the trusted assessor model. Dorset HealthCare, SWASFT and the police are in discussion about operational processes and how they work together when supporting individuals. The trusted assessor model is one way of doing this and we are actively working through what this model might look like. We can certainly see how it could work between SWASFT and Dorset HealthCare and how both organisations could trust the assessments of the other.”

Source location

Response from Dorset Integrated Care Board
Page 1 · response
Published 30 October 2023

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

Review and update Business Continuity Plans to assess adopting Scribe ECS as a secondary fallback system.

Verbatim wording from the response

“I am pleased to confirm that our ECS was successfully reintroduced on Tuesday 10th October 2023. We are also reviewing and updating our Business Continuity Plans which is looking at adopting the Scribe ECS as a secondary fall-back system. This will significantly reduce the possibility of adopting paper PCRs in response to an outage in our primary ECS in the future.”

Source location

Response from South Western Ambulance Service NHS Foundation Trust
Page 2 · response
Published 30 October 2023

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

Introduce a process and document-sharing system giving PAPs access to updated policies when released.

Verbatim wording from the response

“For your assurance, following a previous inquest in June 2023, the Trust introduced a new process and document sharing system with the PAPs. They are now informed and have access to all our updated policies on their release.”

Source location

Response from South Western Ambulance Service NHS Foundation Trust
Page 2 · response
Published 30 October 2023

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

Ensure PAP information is included in Clinical Leads’ Local Clinical Update documents available through the Clinical App.

Verbatim wording from the response

“Furthermore, I have also asked all Clinical Leads across SWASFT to ensure that this is included within their Local Clinical Update documents available via the Clinical App.”

Source location

Response from South Western Ambulance Service NHS Foundation Trust
Page 2 · response
Published 30 October 2023

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

Reintroduce the Electronic Care System for operational use.

Verbatim wording from the response

“I am pleased to confirm that our ECS was successfully reintroduced on Tuesday 10th October 2023. We are also reviewing and updating our Business Continuity Plans which is looking at adopting the Scribe ECS as a secondary fall-back system. This will significantly reduce the possibility of adopting paper PCRs in response to an outage in our primary ECS in the future.”

Source location

Response from South Western Ambulance Service NHS Foundation Trust
Page 2 · response
Published 30 October 2023

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 PAP contract leads of GP referral requirements and require dissemination and acknowledgement from their staff.

Verbatim wording from the response

“I can confirm that we have contacted the central contract leads for all PAPs that are contracted on behalf of SWASFT, reminding them of the current situation regards GP referrals when utilising paper Patient Clinical Records (PCR) or the Scribe ECS system. Specifically, we have referred them to SWASFT’s Appropriate Care Pathway Policy, which all PAPs are required to adhere to, and the requirement for clinicians to make a direct referral to the GP or Out of Hours (OOH) GP service if their patient requires input within 72 hours. They have also been reminded to pass information on to the GP surgery verbally via the GP surgery, OOH GP or 111 where needed. Additionally, the availability of the GP Alert service run by Dorset Integrated Urgent Care Service (IUCS) for passing information to GPs within Dorset has also been brought to their attention.”

Source location

Response from South Western Ambulance Service NHS Foundation Trust
Page 1 · response
Published 30 October 2023

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

Set up SWASFT Clinical App accounts for St John Ambulance staff supporting the Trust.

Verbatim wording from the response

“During communications with the PAPs, it has been identified that St John Ambulance (SJA) are commissioned directly by the National Ambulance Co-ordination Centre (NACC), which is hosted by West Midlands Ambulance Service University NHS Foundation Trust. The consequence of this is that we do not have direct contract with them, rather the Trust is allocated resources as part of the national NACC contract. SJA currently have between one and four ambulances supporting SWASFT per day across the South West. As a Trust, we have discussed this directly with SJA who have confirmed that ████████”

Source location

Response from South Western Ambulance Service NHS Foundation Trust
Page 1 · response
Published 30 October 2023

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

Publish the Government’s response to the consultation on statutory healthcare-profession regulation.

Verbatim wording from the response

“We will publish our response to this consultation in due course.”

Source location

Response from Department of Health and Social Care
Page 2 · response
Published 30 October 2023

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

Dorset residents are not left without 24/7 mental-health support because local crisis services provide continuous support and advice.

Verbatim wording from the response

“We note that SWASFT have reported that without the 24/7 help desk people in Dorset are left without MH support that is 24/7; this is not the case. Whilst discussions are ongoing in relation to how we might maximise the benefits for Dorset residents by being partners in the SWASFT MH Desk 24/7, Dorset residents do in fact have access to 24/7 MH support and advice as set out above.”

Source location

Response from Dorset Integrated Care Board
Page 2 · response
Published 30 October 2023

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 local Access Mental Health services are considered sufficient to provide Dorset residents with 24/7 mental-health support without the SWASFT help desk.

Verbatim wording from the response

“Dorset has a well-established service in place to support their residents who are in crisis, namely the “Access Mental Health” service provided by Dorset HealthCare. Access Mental Health has been operational since 2017/18 and offers the following:”

Source location

Response from Dorset Integrated Care Board
Page 1 · response
Published 30 October 2023

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