PFD report

Ann Margaret SPEARING · Prevention of Future Deaths report

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Issued 20 Aug 2013•Avon

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
1

Named on the report

Responses found
1

Of 1 recipient

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 raised2

  1. Lack of funding provision for such cases
  2. Failure of relevant organisations to provide care for people excluded by their eligibility criteria
    Part of recurring concern: Failure to provide care for vulnerable people excluded by service thresholds
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

    Implement a primary-care psychotherapy service for people unsuitable for or unable to engage with existing services and those below referral thresholds.

    Stated by NHS Bristol, North Somerset and South Gloucestershire Integrated Care BoardStated in progressThe respondent said that this action was in progress when they made their response on 20 August 2013.
  2. Action

    Re-procure redesigned specialist mental health and learning disability services.

    Stated by NHS Bristol, North Somerset and South Gloucestershire Integrated Care BoardStated in progressThe respondent said that this action was in progress when they made their response on 20 August 2013.
  3. Action

    Operate Primary Care Liaison as a single point of access, providing triage, primary-care advice, assessment routing and pathway facilitation.

    Stated by NHS Bristol, North Somerset and South Gloucestershire Integrated Care BoardStated completedThe respondent said that this action was complete when they made their response on 20 August 2013.

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 funding provision for such cases

Wider context from the report

“The concerns are that despite the involvement of all the relevant organisations this lady was able to precipitate her death by starving herself over a period of many months leading her GP to predict her death some months in advance. It appears that each of the relevant organisations had drawn their criteria in such a way as to exclude this lady from their care. She was always someone else's problem. There needs to be some method of providing funding in such cases rather than spending time and money passing the person from one agency to another without any positive curative action being taken. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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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 of relevant organisations to provide care for people excluded by their eligibility criteria

Wider context from the report

“The concerns are that despite the involvement of all the relevant organisations this lady was able to precipitate her death by starving herself over a period of many months leading her GP to predict her death some months in advance. It appears that each of the relevant organisations had drawn their criteria in such a way as to exclude this lady from their care. She was always someone else's problem. There needs to be some method of providing funding in such cases rather than spending time and money passing the person from one agency to another without any positive curative action being taken. ”

Is this part of a recurring concern?

Yes — Failure to provide care for vulnerable people excluded by service thresholds.

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

Implement a primary-care psychotherapy service for people unsuitable for or unable to engage with existing services and those below referral thresholds.

Verbatim wording from the response

“A Primary Care Psychotherapy Service which, following a successful pilot, is being implemented in Bristol. Importantly this service will support people such as Miss Spearing who may present with medically unexplained symptoms, or have a diagnosis or characteristics of a personality disorder, who are not suitable for existing secondary mental health services or those who find it difficult to engage with such services. It will also work with patients with mental health problems who have been discharged from services or do not meet the referral threshold for current primary or secondary services.”

Source location

2013-0217-Response-by-Bristol-Clinical-Commissioning-Group
Page 2 · response
Published 20 August 2013

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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

Re-procure redesigned specialist mental health and learning disability services.

Verbatim wording from the response

“Bristol has recently reviewed, redesigned and is currently re-procuring its specialist mental health and learning disability services. This process was undertaken following consultation with users, carers and relevant professionals. It was initiated in response to concerns by all parties that Bristol’s mental health services were neither flexible or”

Source location

2013-0217-Response-by-Bristol-Clinical-Commissioning-Group
Page 1 · response
Published 20 August 2013

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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

Operate Primary Care Liaison as a single point of access, providing triage, primary-care advice, assessment routing and pathway facilitation.

Verbatim wording from the response

“The development of Primary Care Liaison; this service was implemented in 2012 as Single Point of Access to secondary mental health services across Bristol and provides:”

Source location

2013-0217-Response-by-Bristol-Clinical-Commissioning-Group
Page 2 · response
Published 20 August 2013

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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

Provide an expanded primary-care psychological therapies service accessible by self-referral or professional referral.

Verbatim wording from the response

“responsive and that there should be a greater bias towards prevention and providing support closer to the patient’s own home. This process has meant that a significantly expanded range of services will be available from October 2014. These will include interventions for patients with complex presentations or medically unexplained symptoms such as Miss Spearing. We already have in place a significantly expanded primary care based psychological therapies service, directly accessible by self or professional referral.”

Source location

2013-0217-Response-by-Bristol-Clinical-Commissioning-Group
Page 2 · response
Published 20 August 2013

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

Make an expanded range of specialist services available, including interventions for complex presentations and medically unexplained symptoms.

Verbatim wording from the response

“responsive and that there should be a greater bias towards prevention and providing support closer to the patient’s own home. This process has meant that a significantly expanded range of services will be available from October 2014. These will include interventions for patients with complex presentations or medically unexplained symptoms such as Miss Spearing. We already have in place a significantly expanded primary care based psychological therapies service, directly accessible by self or professional referral.”

Source location

2013-0217-Response-by-Bristol-Clinical-Commissioning-Group
Page 2 · response
Published 20 August 2013

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

    Operate the First Step primary-care eating disorder service as a gateway to the eating disorders pathway and deliver evidence-based treatment in GP surgeries.

    Stated by NHS Bristol, North Somerset and South Gloucestershire Integrated Care BoardStated completedThe respondent said that this action was complete when they made their response on 20 August 2013.
  2. 2

    Continue service changes to give every GP practice a nominated psychiatrist for ongoing communication and support.

    Stated by NHS Bristol, North Somerset and South Gloucestershire Integrated Care BoardStated in progressThe respondent said that this action was in progress when they made their response on 20 August 2013.
  3. 3

    Provide enhanced advice and guidance to GPs through clinician forums and direct psychiatrist contact details.

    Stated by NHS Bristol, North Somerset and South Gloucestershire Integrated Care BoardStated completedThe respondent said that this action was complete when they made their response on 20 August 2013.

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

Operate the First Step primary-care eating disorder service as a gateway to the eating disorders pathway and deliver evidence-based treatment in GP surgeries.

Verbatim wording from the response

“A Primary Care Eating Disorder Service, known as ‘First Step’, was launched in July 2013. First Step is a primary care eating disorders service and acts as a gateway to the Trust’s eating disorders care pathway. It delivers evidence-based treatments such as enhanced Cognitive Behaviour Therapy in all GP surgeries across Bristol.”

Source location

2013-0217-Response-by-Bristol-Clinical-Commissioning-Group
Page 2 · response
Published 20 August 2013

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

Continue service changes to give every GP practice a nominated psychiatrist for ongoing communication and support.

Verbatim wording from the response

“There is further work aimed at supporting on-going communication between GPs and Bristol psychiatrists, including further service change to ensure all GP practices have a nominated psychiatrist they can link to”

Source location

2013-0217-Response-by-Bristol-Clinical-Commissioning-Group
Page 3 · response
Published 20 August 2013

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

Provide enhanced advice and guidance to GPs through clinician forums and direct psychiatrist contact details.

Verbatim wording from the response

“To further support GP’s and provide timely advice with complex patients such as Miss Spearing, we have piloted an enhanced advice and guidance support scheme to GPs. This includes regular clinician fora and reassuring GPs with contact details for psychiatrists within their local catchment area mental health teams. This has led to an increase in GPs contacting their psychiatrist colleagues directly by phone and email with clinical queries that require advice but not necessarily referral into the triage service for assessment. This has been felt to be a significant improvement to prior arrangements.”

Source location

2013-0217-Response-by-Bristol-Clinical-Commissioning-Group
Page 3 · response
Published 20 August 2013

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