PFD report

Dean Mark Rowland · Prevention of Future Deaths report

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Issued 27 Jun 2017•Staffordshire South

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
2

Raised in this report

Recipients
2

Named on the report

Responses found
2

Of 2 recipients

Stated actions
1

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 raised2

  1. Failure to provide follow-up after community mental health assessment
    Part of recurring concern: Failure to provide timely and adequate follow-up after dischargePart of recurring concern: Failure to provide timely continuing mental health reviews and follow-upPart of recurring concern: Failure to reliably follow up identified mental-health safety concernsPart of recurring concern: Unreliable Community Mental Health care access and discharge processesPart of recurring concern: Unsafe discharge, closure or withdrawal of mental health services
  2. Delays in access to a GP for medication discussions
    Part of recurring concern: Inadequate GP consultation provision for safe patient assessmentPart of recurring concern: Unclear and unreliable GP access and referral pathways
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.1

  1. Action

    Implement a duty-doctor and telephone-triage system providing prompt callbacks and same-day clinical assessment when routine appointments are unsuitable.

    Stated by Peel Medical PracticeStated completedThe respondent said that this action was complete when they made their response on 12 September 2017.

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

  1. Position

    Existing self-help resources, GP referral routes and CMHT re-referral contacts were considered sufficient without ongoing CMHT follow-up.

    Stated by Midlands Partnership University NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.

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 follow-up after community mental health assessment

Wider context from the report

“(2) He was referred to a community mental health team having made two serious previous suicide attempts. He was discharged after only one consultation with no follow up plan other than for him to refer back to primary care. The family perceived he would have benefitted from a further appointment. He was very willing to engage with services. ”

Is this part of a recurring concern?

Yes — Failure to provide timely and adequate follow-up after discharge; Failure to provide timely continuing mental health reviews and follow-up; Failure to reliably follow up identified mental-health safety concerns; Unreliable Community Mental Health care access and discharge processes; Unsafe discharge, closure or withdrawal of mental health services.

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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

Delays in access to a GP for medication discussions

Wider context from the report

“(1) The deceased wished to discuss an increase in his antidepressant medication with a doctor. He was unable to get an appointment or speak to a GP on the telephone for nine days. ”

Is this part of a recurring concern?

Yes — Inadequate GP consultation provision for safe patient assessment; Unclear and unreliable GP access and referral pathways.

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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

Implement a duty-doctor and telephone-triage system providing prompt callbacks and same-day clinical assessment when routine appointments are unsuitable.

Verbatim wording from the response

“We have instituted a duty doctor and telephone triage system in the practice. If the patient attends or phones the practice requesting an appointment they are told when the next routine appointment is available for the doctor of their choice and for any doctor. If they feel they need to be seen that day or that their condition will not wait until the next available routine appointment they are offered a “callback”. They will be called as soon as possible by one of the duty team who will either deal with the problem over the telephone or make them an appointment that day to see a doctor or a nurse practitioner - whichever is the most appropriate for the problem. This means that everyone who needs to be seen will be seen on the same day.”

Source location

2017-0208-Response-by-Peel-Medical-Practice
Page 1 · response
Published 12 September 2017

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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 self-help resources, GP referral routes and CMHT re-referral contacts were considered sufficient without ongoing CMHT follow-up.

Verbatim wording from the response

“Mr Rowland engaged fully in his assessment and coproduced the plan which was later communicated to him by letter. He felt that the difficulties in his mental health had improved and that he did not require input from the CMHT, but was aware that he could be re-referred at any time should this situation change. The letter validated his efforts to be well and detailed online self-help resources to support these efforts, and also recommended that he register with a GP in Birmingham if he wished to continue to reside there, so that he could be referred quickly to his local mental health services in future should the need arise. If the assessment had highlighted the need for ongoing input from the CMHT, this would have been transferred to the service in Birmingham local to Mr Rowland’s new residence, but as described it was not required.”

Source location

2017-0208-Response-by-South-Staffordshire-and-Shropshire-Healthcare
Page 2 · response
Published 12 September 2017

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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

The assessment found low suicide risk and sufficiently detailed needs assessment, so discharge after one consultation was considered the right decision.

Verbatim wording from the response

“When seen on 19th August 2016, Mr Rowland had moved to Birmingham in order to reside with his mother, and reported improvements in his mental health due to this change of environment and a now amicable relationship with his ex-wife and access to his children. Mr Rowland described his wellbeing “feel like I have my life back and am like my old self” and reported various self-help methods such as exercise and making time for himself. Importantly he expressed no further ideas of suicide. A Patient Health Questionnaire 9 (PHQ-9) was completed as part of the assessment; this is a 9-item questionnaire to explore current symptoms of depression, yielding a score of between 0 and 27. Mr Rowland scored 8, which is indicative of mild depression that would not usually require treatment; scores of 15 and above are usually seen in individuals requiring the input of a CMHT.”

Source location

2017-0208-Response-by-South-Staffordshire-and-Shropshire-Healthcare
Page 2 · response
Published 12 September 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