PFD report

William Abel · Prevention of Future Deaths report

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Issued 20 Oct 2015•Leicester City and South Leicestershire

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
4

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
7

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

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Concerns raised4

  1. Failure to discuss family involvement and provide information about the mental health problem and its treatments
    Part of recurring concern: Failure to establish patients’ consent for family involvement in mental health care
  2. Failure to obtain relevant family information before taking no further action
    Part of recurring concern: Failure to obtain relevant collateral information from family and social supports
  3. Inadequate communication of professional concerns and safe-keeping expectations to family members
    Part of recurring concern: Failure to communicate safety-critical care information effectively between care providers and familiesPart of recurring concern: Failure to involve families and carers in mental health care planning and decisions
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

    Introduce an assessment-outcome and plan form providing patients and, with consent, accompanying carers or family members written advice and access information.

    Stated by Leicestershire Partnership NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 20 October 2015.
  2. Action

    Remind Triage Car and Crisis Team staff about the family-involvement protocol and patient choice through managers and team meetings.

    Stated by Leicestershire Partnership NHS TrustStated completedThe respondent said that this action was complete when they made their response on 20 October 2015.
  3. Action

    Revise the Triage Car Mental Health Act assessment protocol to require consideration and documentation of decisions and reasons.

    Stated by Leicestershire Partnership NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 20 October 2015.

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 discuss family involvement and provide information about the mental health problem and its treatments

Wider context from the report

“3. NICE guidelines (Clinical guidance 136) state that health care professionals should discuss whether the patient would like the family to be involved in their care, and to provide them with information to understand the mental health problem and its treatments. This guideline does not appear to have been met in this case. ”

Is this part of a recurring concern?

Yes — Failure to establish patients’ consent for family involvement in mental health care.

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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 relevant family information before taking no further action

Wider context from the report

“2. Mr Abel was discharged into the care of his father, and inadequate communications were made with the family, as the father was not made aware of the professional concerns regarding a relapse in his mental health, that hospitalisation had been considered and the family was expected to be responsible for his safe keeping. No attempt was made to obtain any family information that could have impacted on the decision to take no further action that night. ”

Is this part of a recurring concern?

Yes — Failure to obtain relevant collateral information from family and social supports.

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

Inadequate communication of professional concerns and safe-keeping expectations to family members

Wider context from the report

“2. Mr Abel was discharged into the care of his father, and inadequate communications were made with the family, as the father was not made aware of the professional concerns regarding a relapse in his mental health, that hospitalisation had been considered and the family was expected to be responsible for his safe keeping. No attempt was made to obtain any family information that could have impacted on the decision to take no further action that night. ”

Is this part of a recurring concern?

Yes — Failure to communicate safety-critical care information effectively between care providers and families; Failure to involve families and carers in mental health care planning and decisions.

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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 a Mental Health Assessment after a person expressing suicidal intention was safely escorted from railway lines

Wider context from the report

“1. Mr Abel had a diagnosis of paranoid schizophrenia and he was still under the care of the Mental Health services at the time he was found in the vicinity of the railway lines, expressing suicidal intention. He had missed appointments and there was a history of non-compliance with medication. Staff were available to have conducted a Mental Health Assessment, on the night he was safely escorted from the railway lines, but this was not done. ”

Is this part of a recurring concern?

Yes — Failure to provide timely and competent mental health assessment after self-harm.

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

Introduce an assessment-outcome and plan form providing patients and, with consent, accompanying carers or family members written advice and access information.

Verbatim wording from the response

“The service is introducing an outcome of assessment and plan record form to support the routine work of the Triage Car and Crisis Teams, ensuring that all patients come into contact with the Triage Car Mental Health Practitioner team are given key written information clarifying the immediate advice given, and where and how to access help should they need it. This will also be given to a carer, friend or family member if they are present at the assessment and the patient has consented to their involvement. We will implement this change for the Triage Car team by the end of December 2015 and the wider Crisis Team by the end of January 2015.”

Source location

2015-0406-Response-by-Leicester-Partnership-NHS-Trust
Page 3 · response
Published 20 October 2015

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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

Remind Triage Car and Crisis Team staff about the family-involvement protocol and patient choice through managers and team meetings.

Verbatim wording from the response

“The Triage Car and Crisis Team have both been reminded of this protocol via their team manager and their team meetings during November 2015.”

Source location

2015-0406-Response-by-Leicester-Partnership-NHS-Trust
Page 3 · response
Published 20 October 2015

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

Revise the Triage Car Mental Health Act assessment protocol to require consideration and documentation of decisions and reasons.

Verbatim wording from the response

“The protocol for Mental Health Practitioners working with the Triage Car is being revised so that where there are clear indicators which prompt a discussion with a patient about the possibility of an admission to an Acute Hospital and a patient refuses to consider an informal admission, a Mental Health Act Assessment will be considered. If the assessment is not undertaken, the reasons for this decision taken within the context of the patient’s presentation and the conferences of the contact with the services, will be clearly documented. The changes to the protocol have been communicated via email to the Triage Car and Crisis Team via the service and team managers and the final revised protocol will be discussed in both team meetings. The communication exercise was completed during November 2015.”

Source location

2015-0406-Response-by-Leicester-Partnership-NHS-Trust
Page 2 · response
Published 20 October 2015

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

Audit compliance with the revised Mental Health Act assessment protocol and report findings and further actions.

Verbatim wording from the response

“We will undertake an audit to monitor compliance of the revised protocol in December 2015 and report the audit and further actions to be taken in January 2016.”

Source location

2015-0406-Response-by-Leicester-Partnership-NHS-Trust
Page 2 · response
Published 20 October 2015

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

Document family members’ presence, offer them opportunities to provide views and observations, and include this information in assessment outcomes.

Verbatim wording from the response

“Family members’ presence during an assessment will be documented and we will ensure they are offered the opportunity to give their views, observations and understanding in relation to the crisis and the support required of them by the individual. This information will be documented on the assessment form by the assessing professional and form part of the outcome of assessment.”

Source location

2015-0406-Response-by-Leicester-Partnership-NHS-Trust
Page 3 · response
Published 20 October 2015

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.2

  1. 1

    Communicate the revised Mental Health Act assessment protocol to Triage Car and Crisis Team staff.

    Stated by Leicestershire Partnership NHS TrustStated completedThe respondent said that this action was complete when they made their response on 20 October 2015.
  2. 2

    Complete the nurse’s detailed reflective-practice programme under Senior Matron supervision.

    Stated by Leicestershire Partnership NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 20 October 2015.

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

Communicate the revised Mental Health Act assessment protocol to Triage Car and Crisis Team staff.

Verbatim wording from the response

“The protocol for Mental Health Practitioners working with the Triage Car is being revised so that where there are clear indicators which prompt a discussion with a patient about the possibility of an admission to an Acute Hospital and a patient refuses to consider an informal admission, a Mental Health Act Assessment will be considered. If the assessment is not undertaken, the reasons for this decision taken within the context of the patient’s presentation and the conferences of the contact with the services, will be clearly documented. The changes to the protocol have been communicated via email to the Triage Car and Crisis Team via the service and team managers and the final revised protocol will be discussed in both team meetings. The communication exercise was completed during November 2015.”

Source location

2015-0406-Response-by-Leicester-Partnership-NHS-Trust
Page 2 · response
Published 20 October 2015

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 the nurse’s detailed reflective-practice programme under Senior Matron supervision.

Verbatim wording from the response

“The nurse concerned is undergoing a detailed programme of reflective practice led by the service’s Senior Matron. This will be fully completed by December 2015.”

Source location

2015-0406-Response-by-Leicester-Partnership-NHS-Trust
Page 2 · response
Published 20 October 2015

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