Suzanne Julia ELLERBY · Prevention of Future Deaths report

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Issued 14 Nov 2025•Surrey

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
3

Raised in this report

Recipients
2

Named on the report

Responses found
2

Of 2 recipients

Stated actions
2

Described in responses

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

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Report evidence summary

Concerns raised3

  1. Lack of universal guidance for timely primary care follow-up of vulnerable mental health patients transferred from secondary services
    Part of recurring concern: Failure to maintain primary-care involvement in patients’ changing mental-health needsPart of recurring concern: Failure to provide timely continuing mental health reviews and follow-upPart of recurring concern: Unsafe coordination and continuity during mental health service transfers
  2. Lack of safety-netting arrangements for timely primary care follow-up of vulnerable mental health patients transferred from secondary services
    Part of recurring concern: Failure to maintain primary-care involvement in patients’ changing mental-health needsPart of recurring concern: Failure to provide timely continuing mental health reviews and follow-upPart of recurring concern: Unsafe coordination and continuity during mental health service transfers
  3. Failure of secondary mental health services to ensure primary care follow-up has been undertaken after transfer
    Part of recurring concern: Failure to integrate mental health services across care settingsPart of recurring concern: Failure to provide timely continuing mental health reviews and follow-upPart of recurring concern: Unsafe coordination and continuity during mental health service transfers

Stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.2

  1. NHS England

    Discuss all Prevention of Future Deaths reports through the Regulation 28 Working Group and share key learning across national and regional NHS services.

  2. NHS England

    Draft and share the Personalised Care Framework with systems to support early adoption of safer mental-health care transitions.

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 universal guidance for timely primary care follow-up of vulnerable mental health patients transferred from secondary services

Wider context from the report

“Surrey and Borders and Madeira Medical Practice have both recognised the risk of the transfer period from secondary to primary mental health care in vulnerable patients, and have put in hand changes within their organisations to address this. However, as highlighted by Madeira Medical Practice: “there is no expectation from NHS England or mental health services to following up these patients urgently”, and therefore no universal guidance for all mental health trusts and GP practices. There are no safety netting guidelines or policies in place to ensure vulnerable mental health patients are followed up within a timely period by primary care services on transfer from secondary services, nor expectations on secondary services to ensure this has been undertaken by primary care services. Patients are therefore being relied upon to ensure this takes place, at a time when they are particularly vulnerable. - Vulnerable patients are often transferred back to primary care by mental health services for their onward care, which is effected by way of a Discharge Letter; - NHS England has not provided any guidance in respect of expectation for follow up by primary care services when this transfer takes place; - In the absence of such guidance, the onus is on vulnerable patients to ensure they follow up their care with their GP, without any safety netting in place should they fail to do so. ”

Is this part of a recurring concern?

Yes — Failure to maintain primary-care involvement in patients’ changing mental-health needs; Failure to provide timely continuing mental health reviews and follow-up; Unsafe coordination and continuity during mental health service transfers.

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 safety-netting arrangements for timely primary care follow-up of vulnerable mental health patients transferred from secondary services

Wider context from the report

“Surrey and Borders and Madeira Medical Practice have both recognised the risk of the transfer period from secondary to primary mental health care in vulnerable patients, and have put in hand changes within their organisations to address this. However, as highlighted by Madeira Medical Practice: “there is no expectation from NHS England or mental health services to following up these patients urgently”, and therefore no universal guidance for all mental health trusts and GP practices. There are no safety netting guidelines or policies in place to ensure vulnerable mental health patients are followed up within a timely period by primary care services on transfer from secondary services, nor expectations on secondary services to ensure this has been undertaken by primary care services. Patients are therefore being relied upon to ensure this takes place, at a time when they are particularly vulnerable. - Vulnerable patients are often transferred back to primary care by mental health services for their onward care, which is effected by way of a Discharge Letter; - NHS England has not provided any guidance in respect of expectation for follow up by primary care services when this transfer takes place; - In the absence of such guidance, the onus is on vulnerable patients to ensure they follow up their care with their GP, without any safety netting in place should they fail to do so. ”

Is this part of a recurring concern?

Yes — Failure to maintain primary-care involvement in patients’ changing mental-health needs; Failure to provide timely continuing mental health reviews and follow-up; Unsafe coordination and continuity during mental health service transfers.

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 of secondary mental health services to ensure primary care follow-up has been undertaken after transfer

Wider context from the report

“Surrey and Borders and Madeira Medical Practice have both recognised the risk of the transfer period from secondary to primary mental health care in vulnerable patients, and have put in hand changes within their organisations to address this. However, as highlighted by Madeira Medical Practice: “there is no expectation from NHS England or mental health services to following up these patients urgently”, and therefore no universal guidance for all mental health trusts and GP practices. There are no safety netting guidelines or policies in place to ensure vulnerable mental health patients are followed up within a timely period by primary care services on transfer from secondary services, nor expectations on secondary services to ensure this has been undertaken by primary care services. Patients are therefore being relied upon to ensure this takes place, at a time when they are particularly vulnerable. - Vulnerable patients are often transferred back to primary care by mental health services for their onward care, which is effected by way of a Discharge Letter; - NHS England has not provided any guidance in respect of expectation for follow up by primary care services when this transfer takes place; - In the absence of such guidance, the onus is on vulnerable patients to ensure they follow up their care with their GP, without any safety netting in place should they fail to do so. ”

Is this part of a recurring concern?

Yes — Failure to integrate mental health services across care settings; Failure to provide timely continuing mental health reviews and follow-up; Unsafe coordination and continuity during mental health service transfers.

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

Discuss all Prevention of Future Deaths reports through the Regulation 28 Working Group and share key learning across national and regional NHS services.

Verbatim wording from the response

“I would also like to provide further assurances on the national NHS England work taking place around the Reports to Prevent Future Deaths. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors, and other clinical and quality colleagues from across the regions. This ensures that key learnings and insights around events, such as the sad death of Suzanne, are shared across the NHS at both a national and regional level and helps us to pay close attention to any emerging trends that may require further review and action.”

Source location

Response from NHS England
Page 3 · response
Published 18 November 2025

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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

Draft and share the Personalised Care Framework with systems to support early adoption of safer mental-health care transitions.

Verbatim wording from the response

“NHS England continues to support systems to improve care for people with mental health problems needing help from secondary mental health services. NHS England has drafted guidance called the Personalised Care Framework (PCF), that sets out the core aspects of care for people who require help from secondary or integrated primary health services, the Voluntary Community and Social Enterprise (VCSE) and secondary care mental health services. It has been shared as a draft with systems to facilitate early adoption.”

Source location

Response from NHS England
Page 1 · response
Published 18 November 2025

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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Official responses located
2/2

Data last updated 7 September 2026