PFD report

Daniel Graeme Futers · Prevention of Future Deaths report

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Issued 2 Feb 2023•Sunderland

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
3

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
3

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 raised3

  1. Lack of comprehensive planning for home leave and discharge from hospital
    Part of recurring concern: Unreliable hospital discharge processes
  2. Failure to maintain overall situational awareness about the patient
  3. Inadequate recording of information conveyed by telephone
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

    Include contingency planning to reduce repeat self-harm risk in updated Trust training materials.

    Stated by Cumbria, Northumberland, Tyne and Wear NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 13 February 2023.
  2. Action

    Improve communication with carers and family members through disseminating lessons learned, training and continuous audit.

    Stated by Cumbria, Northumberland, Tyne and Wear NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 13 February 2023.

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

  1. Position

    The Trust disputes that information recording was inadequate, stating relevant information was documented or not reported to staff.

    Stated by Cumbria, Northumberland, Tyne and Wear NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

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 comprehensive planning for home leave and discharge from hospital

Wider context from the report

“2. Comprehensive planning for home leave and discharge from hospital was not evident, including contingency planning and the involvement of the family. ”

Is this part of a recurring concern?

Yes — Unreliable hospital discharge processes.

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 to maintain overall situational awareness about the patient

Wider context from the report

“3. Overall situational awareness about Daniel was not evident, including the reconciliation of conflicting accounts about him. ”

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

Inadequate recording of information conveyed by telephone

Wider context from the report

“1. The recording of information, particularly that conveyed by telephone, was not as comprehensive as it ought to have been. For example, a record of an alteration had not been made. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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

Include contingency planning to reduce repeat self-harm risk in updated Trust training materials.

Verbatim wording from the response

“c. The risk assessment and associated plan is appropriate, the clinician and patient have a full and open discussion about risk and then between the point of the assessment and the incident, something changes to escalate risk that the clinician could not be aware of or have foreseen. Again, there are limits to the extent to which this can be mitigated against, however contingency planning to reduce the risk of a repeat self-harm attempt is specifically covered in the updated Trust training materials. Contingency and safety planning was evident in this case.”

Source location

Response from Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust
Page 5 · response
Published 13 February 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

Improve communication with carers and family members through disseminating lessons learned, training and continuous audit.

Verbatim wording from the response

“In respect of communication with carers/family members, this is a matter which the Trust takes very seriously and acknowledges is an important part of patient care and treatment. The Trust is continuously driving improvement in this area by way of the dissemination of lessons learned, training and continuous audit.”

Source location

Response from Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust
Page 6 · response
Published 13 February 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

The Trust disputes that information recording was inadequate, stating relevant information was documented or not reported to staff.

Verbatim wording from the response

“It is therefore entirely unfair and disproportionate to criticise the Trust for its recording of information, or alleged lack thereof, when such information was not reported.”

Source location

Response from Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust
Page 2 · response
Published 13 February 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

The Trust disputes that conflicting accounts of Daniel’s presentation existed during leave and therefore required reconciliation.

Verbatim wording from the response

“HM Coroner is referred to the response provided above in respect of the reconciliation of alleged conflicting accounts about Daniel’s presentation. On the basis of the live evidence heard during the inquest hearing and the conversations/reviews by clinicians documented in Daniel’s medical records, there were no apparent conflicting accounts of Daniel’s mental health and presentation during his s.17 leave. As set out above, it is accepted that Daniel’s mum reported him as being bored and anxious during the leave. It was clear from the evidence of the Trust and the family that no additional concerns had been reported in respect of Daniel’s leave. We therefore cannot see that there were any”

Source location

Response from Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust
Page 4 · response
Published 13 February 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

The Trust considers the risk assessment, safety plan and contingency planning appropriate to known circumstances and sufficient to mitigate risks.

Verbatim wording from the response

“b. The risk assessment and associated plan is appropriate to the known circumstances however an individual has not disclosed their true thoughts and intentions in the course of the assessment. The Trust trains its clinicians to mitigate against this risk in so far as possible but there are limitations to what can practically be achieved and the subjective element of risk assessment cannot be eliminated completely. The risk assessments in this case take into account subjective and objective presentation, and collateral information from the family during the leave period. As set out above no issues were identified in the in depth review of the case that suggested a lack of clinical curiosity when considering Daniel’s presentation and treatment plan.”

Source location

Response from Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust
Page 5 · response
Published 13 February 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

The Trust considers multidisciplinary assessment, gradual leave progression, recall powers and monitoring sufficient for leave and discharge planning.

Verbatim wording from the response

“In light of the above, the Trust considers that there had been comprehensive multi-disciplinary consideration of Daniel’s case prior to his s.17 leave being granted which was in line with the Trust policy/procedure in respect of s.17 leave. ████████ explained in his evidence that once Daniel had started to respond to treatment, his leave had been progressed gradually as part of his care and treatment plan alongside his depot medication. ████████ confirmed that there was no reason to suggest that the plan in place was not appropriate and that both Daniel’s subjective and objective presentation were considered in reaching this decision. To the extent that there had been any discrepancy between the objective and subjective presentation, ████████ confirmed that the decision to grant leave would have been reconsidered accordingly.”

Source location

Response from Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust
Page 4 · response
Published 13 February 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.1

  1. 1

    Train clinicians to mitigate the risk that patients do not disclose their true thoughts and intentions during risk assessments.

    Stated by Cumbria, Northumberland, Tyne and Wear NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 13 February 2023.

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

Train clinicians to mitigate the risk that patients do not disclose their true thoughts and intentions during risk assessments.

Verbatim wording from the response

“b. The risk assessment and associated plan is appropriate to the known circumstances however an individual has not disclosed their true thoughts and intentions in the course of the assessment. The Trust trains its clinicians to mitigate against this risk in so far as possible but there are limitations to what can practically be achieved and the subjective element of risk assessment cannot be eliminated completely. The risk assessments in this case take into account subjective and objective presentation, and collateral information from the family during the leave period. As set out above no issues were identified in the in depth review of the case that suggested a lack of clinical curiosity when considering Daniel’s presentation and treatment plan.”

Source location

Response from Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust
Page 5 · response
Published 13 February 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