PFD report

Gwilym Emrys PRICE · Prevention of Future Deaths report

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Issued 10 Jul 2020•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.

View original report
Concerns
1

Raised in this report

Recipients
2

Named on the report

Responses found
4

Of 2 recipients

Stated actions
8

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 raised1

  1. Failure to use the approved referral form for psychiatric referrals to MPFT
    Part of recurring concern: Unreliable mental health 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.5

  1. Action

    Link the Midlands Partnership Foundation Trust and DQS teams to ensure the latest referral form is uploaded to practice clinical systems.

    Stated by East Staffordshire Clinical Commissioning Group and NHS Staffordshire and Stoke-on-Trent Integrated Care Board and North Staffordshire Clinical Commissioning Group and Stoke-on-Trent Clinical Commissioning GroupStated completedThe respondent said that this action was complete when they made their response on 1 October 2020.
  2. Action

    Upload the correct Midlands Partnership Foundation Trust referral form to all GP practice clinical systems and remove previous versions.

    Stated by East Staffordshire Clinical Commissioning Group and NHS Staffordshire and Stoke-on-Trent Integrated Care Board and North Staffordshire Clinical Commissioning Group and Stoke-on-Trent Clinical Commissioning GroupStated plannedThe respondent said that this action was planned when they made their response on 1 October 2020.
  3. Action

    Produce and email all GP practices a standard operating procedure for removing old referral forms and managing updated versions.

    Stated by East Staffordshire Clinical Commissioning Group and NHS Staffordshire and Stoke-on-Trent Integrated Care Board and North Staffordshire Clinical Commissioning Group and Stoke-on-Trent Clinical Commissioning GroupStated plannedThe respondent said that this action was planned when they made their response on 1 October 2020.

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 use the approved referral form for psychiatric referrals to MPFT

Wider context from the report

“shortly prior to his death Emrys was referred by his GP to the Midland Partnership Foundation NHS Trust (MPFT) because of his psychiatric presentation. The GP did not use the type of referral form approved by the MPFT. I understand this has been previously circulated with a request that it is used but this has not yet taken place. I do not believe this affected the treatment that Emrys received but in other case it could lead to referrals being given an incorrect degree of priority. ”

Is this part of a recurring concern?

Yes — Unreliable mental health referral pathways.

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

Link the Midlands Partnership Foundation Trust and DQS teams to ensure the latest referral form is uploaded to practice clinical systems.

Verbatim wording from the response

“1. Clinical Commissioning Group (CCG) to link Midlands Partnership Foundation Team and the DQS Team to ensure the most up to date referral form is uploaded onto the practice clinical systems. | ████████ | 28/08/2020 | Complete”

Source location

2020-0141-Response-from-Clinical-Commissioning-Groups_Redacted.pdf
Page 2 · response
Published 1 October 2020

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

Upload the correct Midlands Partnership Foundation Trust referral form to all GP practice clinical systems and remove previous versions.

Verbatim wording from the response

“3. DQS Team to upload the correct Midlands Partnership Foundation Trust referral form onto all GP Practice clinical systems and ensure any previous versions are removed. | ████████ ████████ | 09/09/2020 |”

Source location

2020-0141-Response-from-Clinical-Commissioning-Groups_Redacted.pdf
Page 2 · response
Published 1 October 2020

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

Produce and email all GP practices a standard operating procedure for removing old referral forms and managing updated versions.

Verbatim wording from the response

“7. CCGs and DQS Team to produce a Standard Operating Procedure (SOP) for removing old referral forms and managing updated versions. This will be emailed out to all GP Practices. | ████████ ████████████ ██████ | 09/09/2020 |”

Source location

2020-0141-Response-from-Clinical-Commissioning-Groups_Redacted.pdf
Page 3 · response
Published 1 October 2020

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

Confirm to the CCGs that the correct referral form is available to all GP practices and the old version has been removed.

Verbatim wording from the response

“4. DQS to confirm to the CCGs that the correct referral form is now available to all GP Practices and that the old referral form has been removed. | ████████ ████████ | 09/09/2020 |”

Source location

2020-0141-Response-from-Clinical-Commissioning-Groups_Redacted.pdf
Page 2 · response
Published 1 October 2020

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 governance-approved process across Primary Care, Commissioning and DQS for managing and appropriately updating referral forms.

Verbatim wording from the response

“8. The CCGs to develop a robust process within Primary Care, Commissioning and the DQS Team to ensure referral forms are managed, updated appropriately and approved through governance processes. | ████████████ ██████ ████████ | 30/09/2020 |”

Source location

2020-0141-Response-from-Clinical-Commissioning-Groups_Redacted.pdf
Page 3 · response
Published 1 October 2020

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.3

  1. 1

    Produce a standard operating procedure for dealing with Coroner Regulation 28 responses.

    Stated by East Staffordshire Clinical Commissioning Group and NHS Staffordshire and Stoke-on-Trent Integrated Care Board and North Staffordshire Clinical Commissioning Group and Stoke-on-Trent Clinical Commissioning GroupStated plannedThe respondent said that this action was planned when they made their response on 1 October 2020.
  2. 2

    Send all GP practices communications highlighting the need to report notifications of incorrect referral forms through the CCGs’ DATIX process.

    Stated by East Staffordshire Clinical Commissioning Group and NHS Staffordshire and Stoke-on-Trent Integrated Care Board and North Staffordshire Clinical Commissioning Group and Stoke-on-Trent Clinical Commissioning GroupStated plannedThe respondent said that this action was planned when they made their response on 1 October 2020.
  3. 3

    Discuss information-sharing processes with Midlands Partnership Foundation Trust and ask whether the incorrect referral form was recorded on its DATIX system.

    Stated by East Staffordshire Clinical Commissioning Group and NHS Staffordshire and Stoke-on-Trent Integrated Care Board and North Staffordshire Clinical Commissioning Group and Stoke-on-Trent Clinical Commissioning GroupStated plannedThe respondent said that this action was planned when they made their response on 1 October 2020.

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

Produce a standard operating procedure for dealing with Coroner Regulation 28 responses.

Verbatim wording from the response

“10. The Primary Care Team to produce a SOP for dealing with Coroner Regulation28 responses. | ████████ | 16/09/2020 |”

Source location

2020-0141-Response-from-Clinical-Commissioning-Groups_Redacted.pdf
Page 3 · response
Published 1 October 2020

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

Send all GP practices communications highlighting the need to report notifications of incorrect referral forms through the CCGs’ DATIX process.

Verbatim wording from the response

“6. The CCGs Primary Care Team to send communications out to all GP Practices highlighting the need for practices to report any notification of incorrect referral forms through the CCGs DATIX process. | ████████ | 09/09/2020 |”

Source location

2020-0141-Response-from-Clinical-Commissioning-Groups_Redacted.pdf
Page 2 · response
Published 1 October 2020

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

Discuss information-sharing processes with Midlands Partnership Foundation Trust and ask whether the incorrect referral form was recorded on its DATIX system.

Verbatim wording from the response

“5. The CCGs Quality Team to discuss information sharing processes with Midlands Partnership Foundation Trust and ask if they had put an entry of the incorrect referral form onto their DATIX system. | ████████ ████████████ ████████ | 09/09/2020 |”

Source location

2020-0141-Response-from-Clinical-Commissioning-Groups_Redacted.pdf
Page 2 · response
Published 1 October 2020

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