PFD report

Anthony Hayward BUCKINGHAM · Prevention of Future Deaths report

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Issued 9 Apr 2019•Suffolk

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
5

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
6

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 raised5

  1. Failure to involve the practice nurse in care
  2. Failure to provide daily visits from the mental health team
    Part of recurring concern: Failure to provide required daily mental-health team visits
  3. Failure to involve the next of kin in care
    Part 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.2

  1. Action

    Allocate a responsible staff member for each service user to coordinate comprehensive care packages and engagement with other agencies.

    Stated by Norfolk and Suffolk NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 18 June 2019.
  2. Action

    Evaluate next-of-kin processes, require corrective action, and monitor improvement through audit and quality and safety reviews.

    Stated by Norfolk and Suffolk NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 18 June 2019.

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

  1. Position

    Existing staff allocation and multidisciplinary meetings identify and coordinate other agencies involved in a service user's care, including practice nurses.

    Stated by Norfolk and Suffolk 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 involve the practice nurse in care

Wider context from the report

“At the Inquest it was highlighted the following could have been done to try and prevent his death 1/ Daily visits from the mental health team 2/ Involvement of the next of kin (his father) 3/ Formal mental health act assessment 4/ Involvement of the practice nurse 5/ Use of Corner house care facility ”

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

Failure to provide daily visits from the mental health team

Wider context from the report

“At the Inquest it was highlighted the following could have been done to try and prevent his death 1/ Daily visits from the mental health team 2/ Involvement of the next of kin (his father) 3/ Formal mental health act assessment 4/ Involvement of the practice nurse 5/ Use of Corner house care facility ”

Is this part of a recurring concern?

Yes — Failure to provide required daily mental-health team visits.

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 involve the next of kin in care

Wider context from the report

“At the Inquest it was highlighted the following could have been done to try and prevent his death 1/ Daily visits from the mental health team 2/ Involvement of the next of kin (his father) 3/ Formal mental health act assessment 4/ Involvement of the practice nurse 5/ Use of Corner house care facility ”

Is this part of a recurring concern?

Yes — Failure to involve families and carers in mental health care planning and decisions.

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 undertake a formal mental health act assessment

Wider context from the report

“At the Inquest it was highlighted the following could have been done to try and prevent his death 1/ Daily visits from the mental health team 2/ Involvement of the next of kin (his father) 3/ Formal mental health act assessment 4/ Involvement of the practice nurse 5/ Use of Corner house care facility ”

Is this part of a recurring concern?

Yes — Failure to ensure timely and appropriate Mental Health Act assessment.

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 use the Corner house care facility when indicated

Wider context from the report

“At the Inquest it was highlighted the following could have been done to try and prevent his death 1/ Daily visits from the mental health team 2/ Involvement of the next of kin (his father) 3/ Formal mental health act assessment 4/ Involvement of the practice nurse 5/ Use of Corner house care facility ”

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

Allocate a responsible staff member for each service user to coordinate comprehensive care packages and engagement with other agencies.

Verbatim wording from the response

“The Trust's internal investigation identified learning regarding the need to liaise and work with other agencies involved in the care of the service user. The team's current working process is to allocate an individual staff member to each service user; they have some additional responsibilities to ensure the care package is comprehensive and includes all other agencies. In addition, the multi-disciplinary team meetings help identify key others involved in care and allocate action of who will engage them.”

Source location

2019-0123-Response-by-Norfolk-and-Suffolk-NHS-Trust
Page 2 · response
Published 18 June 2019

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

Evaluate next-of-kin processes, require corrective action, and monitor improvement through audit and quality and safety reviews.

Verbatim wording from the response

“The Trust's internal investigation confirmed that the next of kin details were not obtained from Anthony, thereby impacting on their ability to engage his family. This was not picked up during the period of contact with the Home Treatment Team. A recommendation of work was made by the internal investigation resulting in the care team evaluating their processes. The clinical team leader monitors this taking action where required. The Trust obtains assurance of this improvement through means such as audit and its quality and safety reviews.”

Source location

2019-0123-Response-by-Norfolk-and-Suffolk-NHS-Trust
Page 1 · response
Published 18 June 2019

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

Existing staff allocation and multidisciplinary meetings identify and coordinate other agencies involved in a service user's care, including practice nurses.

Verbatim wording from the response

“The Trust's internal investigation identified learning regarding the need to liaise and work with other agencies involved in the care of the service user. The team's current working process is to allocate an individual staff member to each service user; they have some additional responsibilities to ensure the care package is comprehensive and includes all other agencies. In addition, the multi-disciplinary team meetings help identify key others involved in care and allocate action of who will engage them.”

Source location

2019-0123-Response-by-Norfolk-and-Suffolk-NHS-Trust
Page 2 · response
Published 18 June 2019

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 response does not identify a stage requiring mental health legislation assessment; engagement with offered care supported least restrictive treatment.

Verbatim wording from the response

“The report doesn't identify at which stage of care a request for a mental health act assessment may have been appropriate. Following the initial assessment, Anthony was an assessment and was engaged with the appointments and telephone calls offered. This was in keeping with the principle of least restrictive treatment.”

Source location

2019-0123-Response-by-Norfolk-and-Suffolk-NHS-Trust
Page 1 · response
Published 18 June 2019

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

Use of Corner House is not treated as necessary because support is individually assessed and multiple statutory and non-statutory options are available.

Verbatim wording from the response

“It is critical that Trust services engage with other agencies to ensure there are comprehensive packages of care in place for our service users and carers. Such support needs are individual based on assessment. The range of statutory and non-statutory support that is available is significant and ever evolving. Thinking of this wider partner network and the requirement for close working, our suicide prevention lead has hosted two events bringing together non-statutory and statutory agencies, service users and Trust services in order to open channels of communication and raise awareness what each other provides. These events of introduction have been well received leading to the building and strengthening of networks. We have more planned for all areas of the Trust over the coming months.”

Source location

2019-0123-Response-by-Norfolk-and-Suffolk-NHS-Trust
Page 2 · response
Published 18 June 2019

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

Contact frequency is determined flexibly by multidisciplinary assessment and service-user needs, rather than requiring daily mental health team visits.

Verbatim wording from the response

“The Trust's internal investigation identified that Anthony had no contact with mental health services prior to February 2018. Following referral to the Trust he was provided with support by the Home Treatment Team. This team provides short term support for people experiencing acute mental health needs, through visits and telephone calls. From the period 16 February 2018 to 13 March 2018 the team completed seven face to face contacts and seven telephone contacts. The decision as to the frequency of contact is considered by the multi-disciplinary team in conjunction with the service user, based on their presenting needs. The multi-disciplinary team approach assists to ensure all perspectives are considered and the judgement is a shared decision. Through this process contact can be increased and decreased on a flexible basis.”

Source location

2019-0123-Response-by-Norfolk-and-Suffolk-NHS-Trust
Page 1 · response
Published 18 June 2019

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.4

  1. 1

    Host additional cross-agency networking events across all Trust areas.

    Stated by Norfolk and Suffolk NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 18 June 2019.
  2. 2

    Introduce Patient Participation Leads and new Clinical Directors to strengthen local clinical leadership, learning, and implementation of serious-incident recommendations.

    Stated by Norfolk and Suffolk NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 18 June 2019.
  3. 3

    Implement a new governance structure providing combined, tiered oversight for service improvement.

    Stated by Norfolk and Suffolk NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 18 June 2019.
  4. 4

    Host cross-agency events connecting statutory and non-statutory organisations, service users, and Trust services to strengthen care networks.

    Stated by Norfolk and Suffolk NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 18 June 2019.

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

Host additional cross-agency networking events across all Trust areas.

Verbatim wording from the response

“It is critical that Trust services engage with other agencies to ensure there are comprehensive packages of care in place for our service users and carers. Such support needs are individual based on assessment. The range of statutory and non-statutory support that is available is significant and ever evolving. Thinking of this wider partner network and the requirement for close working, our suicide prevention lead has hosted two events bringing together non-statutory and statutory agencies, service users and Trust services in order to open channels of communication and raise awareness what each other provides. These events of introduction have been well received leading to the building and strengthening of networks. We have more planned for all areas of the Trust over the coming months.”

Source location

2019-0123-Response-by-Norfolk-and-Suffolk-NHS-Trust
Page 2 · response
Published 18 June 2019

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

Introduce Patient Participation Leads and new Clinical Directors to strengthen local clinical leadership, learning, and implementation of serious-incident recommendations.

Verbatim wording from the response

“In support of all the above actions the Trust is strengthening its clinical and service leadership to ensure they have the necessary breadth of skills and resource to lead safe and effective services. Of particular note, the Trust will be introducing Patient Participation Leads for each locality, who will work alongside new Clinical Directors to lead the components of quality and patient experience. The Trust is finalising the recruitment to these roles which will be fully effective from September 2019. A key function of this new approach will be the accountability to share learning, implement and monitor recommendations from serious incidents. Their role is to support the local clinical services function effectively, working alongside their network of partner agencies.”

Source location

2019-0123-Response-by-Norfolk-and-Suffolk-NHS-Trust
Page 2 · response
Published 18 June 2019

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

Implement a new governance structure providing combined, tiered oversight for service improvement.

Verbatim wording from the response

“The Trust will gain assurance these interventions are working through a number of indicators. This will include audit, user feedback and the outcomes of quality and safety reviews. To support an effective assurance system, the Trust is implementing a new governance structure enabling a combined and tiered approach that will provide the culture and conditions for improvement.”

Source location

2019-0123-Response-by-Norfolk-and-Suffolk-NHS-Trust
Page 2 · response
Published 18 June 2019

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

Host cross-agency events connecting statutory and non-statutory organisations, service users, and Trust services to strengthen care networks.

Verbatim wording from the response

“It is critical that Trust services engage with other agencies to ensure there are comprehensive packages of care in place for our service users and carers. Such support needs are individual based on assessment. The range of statutory and non-statutory support that is available is significant and ever evolving. Thinking of this wider partner network and the requirement for close working, our suicide prevention lead has hosted two events bringing together non-statutory and statutory agencies, service users and Trust services in order to open channels of communication and raise awareness what each other provides. These events of introduction have been well received leading to the building and strengthening of networks. We have more planned for all areas of the Trust over the coming months.”

Source location

2019-0123-Response-by-Norfolk-and-Suffolk-NHS-Trust
Page 2 · response
Published 18 June 2019

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